Provider Demographics
NPI:1285883769
Name:TRINITY UROLOGICAL AND SURGICAL, INC.
Entity type:Organization
Organization Name:TRINITY UROLOGICAL AND SURGICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:YACOUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-720-9204
Mailing Address - Street 1:126 S MONTEBELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4730
Mailing Address - Country:US
Mailing Address - Phone:323-720-9204
Mailing Address - Fax:323-720-9208
Practice Address - Street 1:101 E BEVERLY BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4316
Practice Address - Country:US
Practice Address - Phone:323-728-9300
Practice Address - Fax:323-728-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40189208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0070630Medicaid
CAW13112OtherMEDICARE