Provider Demographics
NPI:1902856685
Name:TRINITY MISSION OF DIBOLL, LLC
Entity Type:Organization
Organization Name:TRINITY MISSION OF DIBOLL, LLC
Other - Org Name:TRINITY MISSION HEALTH & REHAB OF DIBOLL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:2723 SUMMER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-2858
Mailing Address - Country:US
Mailing Address - Phone:901-937-7994
Mailing Address - Fax:901-937-1516
Practice Address - Street 1:900 S TEMPLE DR
Practice Address - Street 2:
Practice Address - City:DIBOLL
Practice Address - State:TX
Practice Address - Zip Code:75941-2725
Practice Address - Country:US
Practice Address - Phone:936-829-5501
Practice Address - Fax:936-829-5503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT DOVE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114018314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001923Medicaid
TX67-5907Medicare ID - Type Unspecified
675907Medicare Oscar/Certification