Provider Demographics
NPI:1679221840
Name:CARROLL, TRINITY
Entity Type:Individual
Prefix:
First Name:TRINITY
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 S GREATHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3434
Mailing Address - Country:US
Mailing Address - Phone:580-889-3553
Mailing Address - Fax:580-889-4050
Practice Address - Street 1:1680 S GREATHOUSE DRIVE
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-7452
Practice Address - Country:US
Practice Address - Phone:580-889-3553
Practice Address - Fax:580-889-4050
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-12-14
Deactivation Date:2022-10-07
Deactivation Code:
Reactivation Date:2022-12-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100683770AMedicaid