Provider Demographics
NPI:1760531016
Name:TRIUMPH LLC
Entity Type:Organization
Organization Name:TRIUMPH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TALESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-256-0824
Mailing Address - Street 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:105 W CORBIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2192
Practice Address - Country:US
Practice Address - Phone:919-245-1056
Practice Address - Fax:919-245-1057
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIUMPH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-09
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 1041C0700X
NC103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005872Medicaid
NC2335621AMedicare PIN
NC2335621BMedicare PIN
NC2335621Medicare PIN