Provider Demographics
NPI:1841382173
Name:TRINITY WELLNESS CENTER OF WILMINGTON INC
Entity Type:Organization
Organization Name:TRINITY WELLNESS CENTER OF WILMINGTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANO
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-343-8424
Mailing Address - Street 1:1907 S 17TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6626
Mailing Address - Country:US
Mailing Address - Phone:910-343-8424
Mailing Address - Fax:910-343-6989
Practice Address - Street 1:1907 S 17TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6626
Practice Address - Country:US
Practice Address - Phone:910-343-8424
Practice Address - Fax:910-343-6989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96001122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005578Medicaid
NC5900768Medicaid
NC6005578Medicaid