Provider Demographics
NPI:1487394672
Name:TRIVIUM HEALTH & NUTRITION PLLC
Entity type:Organization
Organization Name:TRIVIUM HEALTH & NUTRITION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:405-240-9240
Mailing Address - Street 1:309 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-3005
Mailing Address - Country:US
Mailing Address - Phone:405-240-9240
Mailing Address - Fax:405-296-1933
Practice Address - Street 1:309 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3005
Practice Address - Country:US
Practice Address - Phone:405-240-9240
Practice Address - Fax:405-296-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-29
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8067377OtherCIGNA
OK6228274OtherAETNA