Provider Demographics
NPI:1619364262
Name:TRIDENT LABS, INC.
Entity Type:Organization
Organization Name:TRIDENT LABS, INC.
Other - Org Name:TRIDENT LABS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-510-8125
Mailing Address - Street 1:242 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-6518
Mailing Address - Country:US
Mailing Address - Phone:855-875-2532
Mailing Address - Fax:
Practice Address - Street 1:242 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-6518
Practice Address - Country:US
Practice Address - Phone:855-875-2532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory