Basic Information
Provider Information | |||||||||
NPI: | 1427629724 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRINITY LIFE SUPPORT COMMUNITY SERVICE DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2907 | ||||||||
Address2: |   | ||||||||
City: | WEAVERVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 960932907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306232500 | ||||||||
FaxNumber: | 5306232614 | ||||||||
Practice Location | |||||||||
Address1: | 610 WASHINGTON STREET | ||||||||
Address2: |   | ||||||||
City: | WEAVERVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 960932907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306232500 | ||||||||
FaxNumber: | 5306232614 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2021 | ||||||||
LastUpdateDate: | 07/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RATLIFF | ||||||||
AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
AuthorizedOfficialMiddleName: | LYNNE | ||||||||
AuthorizedOfficialTitleorPosition: | PARAMEDIC/FINANCE | ||||||||
AuthorizedOfficialTelephone: | 5306232500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   |   | Y |   | Transportation Services | Ambulance |   |
No ID Information.