Basic Information
| Provider Information | |||||||||
| NPI: | 1770639718 | ||||||||
| 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: | 909 S MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272155756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362295905 | ||||||||
| FaxNumber: | 3362295906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER MANAGER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9192860824 | ||||||||
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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 | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300785B | 05 | NC | MEDICAID | 8300785G | 05 | NC | MEDICAID | 8300785 | 05 | NC | MEDICAID | 8300785V | 05 | NC | MEDICAID | 8300785H | 05 | NC | MEDICAID |