Provider Demographics
NPI:1003040965
Name:TRISOUTH CAP SERVICES
Entity Type:Organization
Organization Name:TRISOUTH CAP SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSW
Authorized Official - Phone:704-493-3422
Mailing Address - Street 1:PO BOX 242036
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28224-2036
Mailing Address - Country:US
Mailing Address - Phone:704-525-2505
Mailing Address - Fax:704-525-2506
Practice Address - Street 1:756 TYVOLA RD
Practice Address - Street 2:SUITE 143
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3588
Practice Address - Country:US
Practice Address - Phone:704-525-2505
Practice Address - Fax:704-525-2506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRISOUTH HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3525251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418482Medicaid