Provider Demographics
NPI:1558559070
Name:TRINITY MEDICAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:TRINITY MEDICAL MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-588-0199
Mailing Address - Street 1:1702 S DIXIE HWY
Mailing Address - Street 2:STE 2
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-5886
Mailing Address - Country:US
Mailing Address - Phone:561-588-0199
Mailing Address - Fax:561-588-0215
Practice Address - Street 1:1702 S DIXIE HWY
Practice Address - Street 2:STE 2
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-5886
Practice Address - Country:US
Practice Address - Phone:561-588-0199
Practice Address - Fax:561-588-0215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86283302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260789100Medicaid
FL260789100Medicaid