Basic Information
| Provider Information | |||||||||
| NPI: | 1093304156 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIEDMONT TRIAD REGIONAL DEVELOPMENT CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1398 CARROLLTON CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369040300 | ||||||||
| FaxNumber: | 3369040336 | ||||||||
| Practice Location | |||||||||
| Address1: | 1398 CARROLLTON CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369040300 | ||||||||
| FaxNumber: | 3369040336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2021 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | DOLGE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3369040300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 172V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker |
No ID Information.