Basic Information
| Provider Information | |||||||||
| NPI: | 1255898953 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN TRINITY HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRINITY DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7 | ||||||||
| Address2: | |||||||||
| City: | SCOTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955650007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077645617 | ||||||||
| FaxNumber: | 7077835618 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HORSESHOE LANE | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306238888 | ||||||||
| FaxNumber: | 5306238887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUPTON | ||||||||
| AuthorizedOfficialFirstName: | GRAYLAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7075746616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | ZZZ80700Z | 01 | CA | MEDICARE PIN | OTHER | RHM70040F | 05 | CA | MEDICAID | 051026 | 05 | CA | MEDICAID | FHC70040F | 05 | CA | MEDICAID |