Provider Demographics
NPI:1467497206
Name:TRIDENT SENIOR HEALTH CENTER
Entity Type:Organization
Organization Name:TRIDENT SENIOR HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-797-0416
Mailing Address - Street 1:2070 NORTHBROOK BLVD
Mailing Address - Street 2:#A16
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9252
Mailing Address - Country:US
Mailing Address - Phone:843-797-0416
Mailing Address - Fax:
Practice Address - Street 1:2070 NORTHBROOK BLVD
Practice Address - Street 2:#A16
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9252
Practice Address - Country:US
Practice Address - Phone:843-797-0416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1196Medicaid
SC=========002OtherBLUE CROSS BLUE SHIELD OF
SCCH6021Medicare PIN
SC=========002OtherBLUE CROSS BLUE SHIELD OF