Provider Demographics
NPI:1902201460
Name:TRINITY PROSTHETIC & ORTHOTICS LLC
Entity Type:Organization
Organization Name:TRINITY PROSTHETIC & ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAIAH
Authorized Official - Middle Name:V
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:601-573-5488
Mailing Address - Street 1:PO BOX 11303
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39283-1303
Mailing Address - Country:US
Mailing Address - Phone:601-573-5488
Mailing Address - Fax:
Practice Address - Street 1:1110 CLAY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2912
Practice Address - Country:US
Practice Address - Phone:601-573-5488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier