Provider Demographics
NPI:1346573169
Name:TRINITY INTERACTIVE PROFESSIONAL SERVICES, LLC
Entity type:Organization
Organization Name:TRINITY INTERACTIVE PROFESSIONAL SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:TATE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:910-520-2921
Mailing Address - Street 1:610 VARSITY DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8444
Mailing Address - Country:US
Mailing Address - Phone:910-520-2921
Mailing Address - Fax:910-793-2819
Practice Address - Street 1:610 VARSITY DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8444
Practice Address - Country:US
Practice Address - Phone:910-520-2921
Practice Address - Fax:910-793-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health