Provider Demographics
NPI:1861708232
Name:TRINITY SUPPORT GROUP, INC
Entity type:Organization
Organization Name:TRINITY SUPPORT GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-207-7674
Mailing Address - Street 1:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29716-0962
Mailing Address - Country:US
Mailing Address - Phone:803-207-7674
Mailing Address - Fax:
Practice Address - Street 1:483 SWEETGUM DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-6927
Practice Address - Country:US
Practice Address - Phone:803-207-7674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103TA0700X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty