Healthcare Provider Details

I. General information

NPI: 1689292625
Provider Name (Legal Business Name): TRIANGLE DIAGNOSTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N JUDD PKWY NE STE 228
FUQUAY VARINA NC
27526-2624
US

IV. Provider business mailing address

320 N JUDD PKWY NE STE 228
FUQUAY VARINA NC
27526-2624
US

V. Phone/Fax

Practice location:
  • Phone: 910-964-4995
  • Fax: 919-367-3399
Mailing address:
  • Phone: 910-964-4995
  • Fax: 919-367-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA SULLIVAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 910-446-1653