Provider Demographics
NPI:1710031273
Name:TRINITY PHYSICAL THERAPY AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:TRINITY PHYSICAL THERAPY AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HARMONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-772-5639
Mailing Address - Street 1:76 BUD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983
Mailing Address - Country:US
Mailing Address - Phone:304-772-5639
Mailing Address - Fax:304-772-4639
Practice Address - Street 1:76 BUD RIDGE RD
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983
Practice Address - Country:US
Practice Address - Phone:304-772-5639
Practice Address - Fax:304-772-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003704Medicaid
WV3810003704Medicaid