Healthcare Provider Details

I. General information

NPI: 1326368390
Provider Name (Legal Business Name): TRG HEALTH CARE SYSTEMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 WHEATON AVE SUITE B
YOUNGSVILLE NC
27596
US

IV. Provider business mailing address

TRG HEALTH CARE SYSTEMS LLC PO BOX 1207
WAKE FOREST NC
27588-1207
US

V. Phone/Fax

Practice location:
  • Phone: 919-925-3604
  • Fax: 919-925-3604
Mailing address:
  • Phone: 919-925-3604
  • Fax: 919-925-3604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EULANDA ELLIOTT
Title or Position: MANAGING MEMBER
Credential:
Phone: 919-925-3804