Provider Demographics
NPI:1568610723
Name:TRIANGLE FAMILY MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:TRIANGLE FAMILY MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELVENTRE'
Authorized Official - Middle Name:SHYTEL
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-978-9118
Mailing Address - Street 1:4005 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8058
Mailing Address - Country:US
Mailing Address - Phone:910-875-6806
Mailing Address - Fax:
Practice Address - Street 1:4005 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-8058
Practice Address - Country:US
Practice Address - Phone:910-875-6806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251B00000X, 251E00000X, 251S00000X, 252Y00000X, 261QA0600X, 261QM0801X, 302F00000X, 332B00000X, 332BX2000X, 341600000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No341600000XTransportation ServicesAmbulance