Healthcare Provider Details

I. General information

NPI: 1144595679
Provider Name (Legal Business Name): TRIAD MEDICAL ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 OLD US HIGHWAY 41 N STE C SUITE C
VALDOSTA GA
31602-6867
US

IV. Provider business mailing address

3790 OLD US HIGHWAY 41 N STE C SUITE C
VALDOSTA GA
31602-6867
US

V. Phone/Fax

Practice location:
  • Phone: 229-241-8811
  • Fax:
Mailing address:
  • Phone: 229-241-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberO-007058
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberO-007058
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberO-007058
License Number StateGA

VIII. Authorized Official

Name: AL TURNER
Title or Position: REGISTERED MANAGER
Credential:
Phone: 229-244-4811