Healthcare Provider Details

I. General information

NPI: 1558417592
Provider Name (Legal Business Name): TRIUMPH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 FAIRHILL DR
RALEIGH NC
27612-3220
US

IV. Provider business mailing address

351 RIVERSIDE DR SUITE 100
MOUNT AIRY NC
27030-3850
US

V. Phone/Fax

Practice location:
  • Phone: 919-256-0824
  • Fax:
Mailing address:
  • Phone: 336-783-6919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: BRENDA FRAZIER
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 919-256-0824