Provider Demographics
NPI:1235793233
Name:TRIVIUM OF MICHIGAN
Entity Type:Organization
Organization Name:TRIVIUM OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NIGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-463-9998
Mailing Address - Street 1:1216 E 86TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4928
Mailing Address - Country:US
Mailing Address - Phone:770-882-9974
Mailing Address - Fax:
Practice Address - Street 1:14800 E 9 MILE RD UNIT 40
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3824
Practice Address - Country:US
Practice Address - Phone:770-882-9974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIVIUM OF NEW YORK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8532047Medicaid