Provider Demographics
NPI:1508005885
Name:TRINITY III FAMILY OUTREACH
Entity Type:Organization
Organization Name:TRINITY III FAMILY OUTREACH
Other - Org Name:TRINITY111
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:804-931-8910
Mailing Address - Street 1:1501 LITTLE GLOUCESTER RD APT F2
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-3445
Mailing Address - Country:US
Mailing Address - Phone:804-931-5910
Mailing Address - Fax:
Practice Address - Street 1:108 SPRUANCE RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4051
Practice Address - Country:US
Practice Address - Phone:804-931-8910
Practice Address - Fax:804-931-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301206Medicaid