Provider Demographics
NPI:1154645513
Name:TRIAD LIFE SERVICES, LLC
Entity Type:Organization
Organization Name:TRIAD LIFE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:PHILLIPIA
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-350-0775
Mailing Address - Street 1:1135 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2733
Mailing Address - Country:US
Mailing Address - Phone:336-227-9028
Mailing Address - Fax:
Practice Address - Street 1:1135 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2733
Practice Address - Country:US
Practice Address - Phone:336-227-9028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL001189251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235377375Medicaid