Provider Demographics
NPI:1063690105
Name:TRINITY PHY-MED LLC
Entity type:Organization
Organization Name:TRINITY PHY-MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWSON
Authorized Official - Middle Name:BLAYNE
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-285-8844
Mailing Address - Street 1:2800 BROWN TRL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-4106
Mailing Address - Country:US
Mailing Address - Phone:817-285-8844
Mailing Address - Fax:817-285-8861
Practice Address - Street 1:2800 BROWN TRL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4106
Practice Address - Country:US
Practice Address - Phone:817-285-8844
Practice Address - Fax:817-285-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C7387 #00540OtherMEDICARE INDIV & GROUP
TXV02075Medicare UPIN