Provider Demographics
NPI:1790962439
Name:TRIUMPH, LLC
Entity Type:Organization
Organization Name:TRIUMPH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MGR./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
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 1:1010 W NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-1105
Practice Address - Country:US
Practice Address - Phone:336-607-8501
Practice Address - Fax:336-725-4030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIUMPH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302304SMedicaid
NC8302304AMedicaid
NC8302304Medicaid
NC8302304Medicaid
NC2335621AMedicare PIN
NC8302304SMedicaid