Basic Information
| Provider Information | |||||||||
| NPI: | 1811176076 | ||||||||
| 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: | 2209 CENTURY DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197864944 | ||||||||
| FaxNumber: | 9197864945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | FRAZIER | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9192560824 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRIUMPH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MLH-092-668 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8302184Q | 05 | NC | MEDICAID | 8302184 | 05 | NC | MEDICAID |