Provider Demographics
NPI:1568564854
Name:TRIAD OPTOMETRIC GROUP PA
Entity Type:Organization
Organization Name:TRIAD OPTOMETRIC GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-782-9091
Mailing Address - Street 1:4151 MAIN @ NORTH HILLS ST
Mailing Address - Street 2:# 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609
Mailing Address - Country:US
Mailing Address - Phone:919-782-9091
Mailing Address - Fax:
Practice Address - Street 1:4151MAIN @ NORTH HILLS ST
Practice Address - Street 2:# 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-782-9091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1585152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2471750Medicare PIN