Provider Demographics
NPI:1760262463
Name:TRIDENT PRIMARY CARE & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:TRIDENT PRIMARY CARE & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-478-8077
Mailing Address - Street 1:6503 GRAND HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-6240
Mailing Address - Country:US
Mailing Address - Phone:678-478-8077
Mailing Address - Fax:
Practice Address - Street 1:875 OLD ROSWELL RD
Practice Address - Street 2:BLDG C, SUITE C-200
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1659
Practice Address - Country:US
Practice Address - Phone:678-731-7000
Practice Address - Fax:678-731-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty