Provider Demographics
NPI:1487881561
Name:TRINITY PROCARE
Entity type:Organization
Organization Name:TRINITY PROCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:COREY
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-273-7501
Mailing Address - Street 1:2752 S STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3859
Mailing Address - Country:US
Mailing Address - Phone:602-531-1658
Mailing Address - Fax:
Practice Address - Street 1:6930 N POLARIS PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2435
Practice Address - Country:US
Practice Address - Phone:928-273-7501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY PROCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102091103T00000X, 175L00000X, 251E00000X
CAH-102091208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No175L00000XOther Service ProvidersHomeopathGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty