Provider Demographics
NPI:1922058304
Name:TRINITY CLINIC
Entity Type:Organization
Organization Name:TRINITY CLINIC
Other - Org Name:TRINITY CLINIC FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR, CENTRAL CRED
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:TIPPIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-531-5185
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:520 EAST DOUGLAS
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702
Practice Address - Country:US
Practice Address - Phone:903-531-5185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T72UMedicare ID - Type Unspecified