Basic Information
| Provider Information | |||||||||
| NPI: | 1215485024 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT TRIAD REGIONAL COUNCIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1398 CARROLLTON CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369040300 | ||||||||
| FaxNumber: | 3369040301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1398 CARROLLTON CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369040300 | ||||||||
| FaxNumber: | 3369040301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | DOLGE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3369040300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.