| Trident Primary Care & Wellness Clinic Llc | |
|
875 Old Roswell Rd Bldg C, Suite C-200 Roswell GA 30076-1659 | |
| (678) 731-7000 | |
| (678) 731-7005 |
| Full Name | Trident Primary Care & Wellness Clinic Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 875 Old Roswell Rd, Roswell, Georgia |
| Authorized Official Name and Position | Roderick Malone (MANAGING MEMBER) |
| Authorized Official Contact | 6784788077 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Trident Primary Care & Wellness Clinic Llc 6503 Grand Hickory Dr Braselton GA 30517-6240 Ph: (678) 478-8077 | Trident Primary Care & Wellness Clinic Llc 875 Old Roswell Rd Bldg C, Suite C-200 Roswell GA 30076-1659 Ph: (678) 731-7000 |
| NPI Number | 1760262463 |
|---|---|
| Provider Enumeration Date | 10/02/2023 |
| Last Update Date | 02/07/2024 |
| Medicare PECOS PAC ID | 6800236316 |
|---|---|
| Medicare Enrollment ID | O20240501002384 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760262463 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Rudolph V Tacoronti |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1962592600 PECOS PAC ID: 1153214010 Enrollment ID: I20040204000747 |
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