Provider Demographics
NPI:1083198501
Name:DE TRINITY COMMUNITY LIVING CORP.
Entity Type:Organization
Organization Name:DE TRINITY COMMUNITY LIVING CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EJOVWOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIESA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-400-4562
Mailing Address - Street 1:25 GORDON RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-3346
Mailing Address - Country:US
Mailing Address - Phone:646-400-4562
Mailing Address - Fax:
Practice Address - Street 1:25 GORDON RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3346
Practice Address - Country:US
Practice Address - Phone:646-400-4562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health