Provider Demographics
NPI:1104001882
Name:TRISOUTH HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:TRISOUTH HEALTH SERVICES, INC
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:704-493-3422
Mailing Address - Fax:
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:704-493-3422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601586Medicaid