Basic Information
| Provider Information | |||||||||
| NPI: | 1275847576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIUMPH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 FAIRHILL DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
| FaxNumber: | 9192560833 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 MEADOWBROOK DR | ||||||||
| Address2: | |||||||||
| City: | KING | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270218248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369853224 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER MGR/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9192560824 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | MHL-085-035 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.