Provider Demographics
NPI:1356724413
Name:TRINA HEALTH-WITCHITA N.W., LLC
Entity type:Organization
Organization Name:TRINA HEALTH-WITCHITA N.W., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEANE'
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-571-9041
Mailing Address - Street 1:8414 W 13TH ST N
Mailing Address - Street 2:STE 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2979
Mailing Address - Country:US
Mailing Address - Phone:214-364-0304
Mailing Address - Fax:866-713-4186
Practice Address - Street 1:8414 W 13TH ST N
Practice Address - Street 2:STE 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-2979
Practice Address - Country:US
Practice Address - Phone:214-364-0304
Practice Address - Fax:866-713-4186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty