Provider Demographics
NPI:1093880213
Name:TRIUMPH LLC
Entity Type:Organization
Organization Name:TRIUMPH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TALESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-256-0824
Mailing Address - Street 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:725 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4833
Practice Address - Country:US
Practice Address - Phone:919-433-1491
Practice Address - Fax:919-433-1498
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIUMPH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-22
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005383Medicaid
NC6005383Medicaid
NC2335621BMedicare PIN
NC2335621Medicare PIN