Basic Information
| Provider Information | |||||||||
| NPI: | 1295810752 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY CONTINUING CARE SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | FRASER VILLA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9184 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483339184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483057919 | ||||||||
| FaxNumber: | 2483057677 | ||||||||
| Practice Location | |||||||||
| Address1: | 33300 UTICA RD | ||||||||
| Address2: | |||||||||
| City: | FRASER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480262017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862933300 | ||||||||
| FaxNumber: | 5862936949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2483057688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 504013 | MI | X | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | X | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 87-3174676 | 05 | MI | MEDICAID |