Basic Information
Provider Information | |||||||||
NPI: | 1689907511 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRIUMPH LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3210 FAIRHILL DR | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276123215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9192560824 | ||||||||
FaxNumber: | 9192560833 | ||||||||
Practice Location | |||||||||
Address1: | 119 W DEPOT ST | ||||||||
Address2: |   | ||||||||
City: | MOCKSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 270282327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367515636 | ||||||||
FaxNumber: | 3367515696 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2009 | ||||||||
LastUpdateDate: | 07/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | HAROLD | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER MANAGER/OWNER | ||||||||
AuthorizedOfficialTelephone: | 9192560824 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.