Provider Demographics
NPI:1114280922
Name:TRIDENTCARE HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:TRIDENTCARE HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:VONSTONE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-514-7322
Mailing Address - Street 1:1200 ABERNATHY RD NE
Mailing Address - Street 2:BUILDING 600, SUITE 1700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5662
Mailing Address - Country:US
Mailing Address - Phone:678-514-7322
Mailing Address - Fax:678-528-5076
Practice Address - Street 1:1200 ABERNATHY RD NE
Practice Address - Street 2:BUILDING 600, SUITE 1700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5662
Practice Address - Country:US
Practice Address - Phone:678-514-7322
Practice Address - Fax:678-528-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
060-R-1032253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care