Provider Demographics
NPI:1295386233
Name:TRINITY DETOX AND FAMILY CLINIC,INC.
Entity Type:Organization
Organization Name:TRINITY DETOX AND FAMILY CLINIC,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:IFEYINWA
Authorized Official - Middle Name:CORDELIA
Authorized Official - Last Name:IBEANU
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:443-326-0503
Mailing Address - Street 1:1232 RACE RD STE 302
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2382
Mailing Address - Country:US
Mailing Address - Phone:443-326-0503
Mailing Address - Fax:
Practice Address - Street 1:1232 RACE RD STE 302
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2382
Practice Address - Country:US
Practice Address - Phone:443-326-0503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty