Healthcare Provider Details

I. General information

NPI: 1518279892
Provider Name (Legal Business Name): TRIUMPH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 FALSTAFF RD
RALEIGH NC
27610-1840
US

IV. Provider business mailing address

3210 FAIRHILL DR
RALEIGH NC
27612-3215
US

V. Phone/Fax

Practice location:
  • Phone: 919-231-9717
  • Fax: 919-231-9754
Mailing address:
  • Phone: 919-256-0824
  • Fax: 919-256-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberMHL-092-779
License Number StateNC

VIII. Authorized Official

Name: HAROLD E JONES JR.
Title or Position: MEMBER MANAGER
Credential:
Phone: 919-256-0824