Provider Demographics
NPI:1760021695
Name:TRIUMPH RESIDENTIAL, LLC
Entity Type:Organization
Organization Name:TRIUMPH RESIDENTIAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:TILLAGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-761-3921
Mailing Address - Street 1:3921 OLD FARM RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-2623
Mailing Address - Country:US
Mailing Address - Phone:757-761-3921
Mailing Address - Fax:
Practice Address - Street 1:3001 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5603
Practice Address - Country:US
Practice Address - Phone:757-761-3921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities