Provider Demographics
NPI:1225226194
Name:THE TRIDENT PACIFIC CORPORATION
Entity Type:Organization
Organization Name:THE TRIDENT PACIFIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-3740
Mailing Address - Street 1:PO BOX 5455
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5455
Mailing Address - Country:US
Mailing Address - Phone:318-212-3740
Mailing Address - Fax:318-212-3758
Practice Address - Street 1:8001 YOUREE DR STE 550
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2325
Practice Address - Country:US
Practice Address - Phone:318-212-3740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CP87Medicare PIN