Provider Demographics
NPI:1982060695
Name:TRIUMPHANT LIFE
Entity Type:Organization
Organization Name:TRIUMPHANT LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:760-646-9174
Mailing Address - Street 1:20851 PAMPUS LN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-8616
Mailing Address - Country:US
Mailing Address - Phone:760-646-9174
Mailing Address - Fax:
Practice Address - Street 1:19923 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5106
Practice Address - Country:US
Practice Address - Phone:760-553-5307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)