Basic Information
| Provider Information | |||||||||
| NPI: | 1679619852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIUMPH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 RIVERSIDE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270303850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367836919 | ||||||||
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| Practice Location | |||||||||
| Address1: | 351 RIVERSIDE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270303850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367836919 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CALDWELL | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9194672433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 8300776G | 05 | NC | MEDICAID | 8300776 | 05 | NC | MEDICAID | 8300776H | 05 | NC | MEDICAID | 8300776B | 05 | NC | MEDICAID |