Provider Demographics
NPI:1124034426
Name:TRINITY VISITING NURSE AND HOMECARE ASSOCIATION
Entity Type:Organization
Organization Name:TRINITY VISITING NURSE AND HOMECARE ASSOCIATION
Other - Org Name:TRINITY PATHWAY HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:309-779-7242
Mailing Address - Street 1:106 19 AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-779-7600
Mailing Address - Fax:309-779-7252
Practice Address - Street 1:106 19TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3700
Practice Address - Country:US
Practice Address - Phone:309-779-7600
Practice Address - Fax:309-779-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2001568251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
96327OtherWELLMARK
9550OtherBLUE CROSS BLUE SHIELD
96326OtherWELLMARK I V
9550OtherBLUE CROSS BLUE SHIELD
IL141583Medicare ID - Type Unspecified