Basic Information
| Provider Information | |||||||||
| NPI: | 1972659993 | ||||||||
| 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: | 276123220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
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| Practice Location | |||||||||
| Address1: | 318 TURNERSBURG HWY | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286252798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048731114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | FRAZIER | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9192560824 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5902798 | 05 | NC | MEDICAID |