Provider Demographics
NPI:1275796112
Name:TRIUMPH, LLC
Entity Type:Organization
Organization Name:TRIUMPH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. MANAGER/PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:TALESHA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:ROLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-256-0824
Mailing Address - Street 1:3210 FAIRHILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3220
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:104 KING CIRCLE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:NC
Practice Address - Zip Code:27016-7634
Practice Address - Country:US
Practice Address - Phone:336-593-8900
Practice Address - Fax:336-593-8973
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIUMPH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2335621Medicare PIN
NC2335621AMedicare PIN
NC2335621BMedicare PIN