Provider Demographics
NPI:1285684258
Name:TRINITY CLINIC
Entity Type:Organization
Organization Name:TRINITY CLINIC
Other - Org Name:TRINITY CLINIC HENDERSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN CLINIC SUPPORT COORDINATO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CMC
Authorized Official - Phone:903-510-1113
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:500 N. MARSHALL
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:75652
Practice Address - Country:US
Practice Address - Phone:903-657-1653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138737503Medicaid