Healthcare Provider Details

I. General information

NPI: 1669161444
Provider Name (Legal Business Name): TRIUMPH LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 ALLEGHENY AVE
COLUMBUS OH
43209-1388
US

IV. Provider business mailing address

1368 CHICKWEED ST
BLACKLICK OH
43004-8333
US

V. Phone/Fax

Practice location:
  • Phone: 330-507-2988
  • Fax:
Mailing address:
  • Phone: 330-507-2988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARCUS STANTON COSPER
Title or Position: OWNER/PA-C
Credential: PA-C
Phone: 330-507-2988