Provider Demographics
NPI:1366538373
Name:TRINITY MARIA, INC
Entity type:Organization
Organization Name:TRINITY MARIA, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KLEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-820-9750
Mailing Address - Street 1:723 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-4611
Mailing Address - Country:US
Mailing Address - Phone:562-437-2797
Mailing Address - Fax:562-437-8688
Practice Address - Street 1:723 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-4611
Practice Address - Country:US
Practice Address - Phone:562-437-2797
Practice Address - Fax:562-437-8688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC05329FMedicaid
CALTC05329FMedicaid