=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760021695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIUMPH RESIDENTIAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2019
-----------------------------------------------------
Last Update Date | 12/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 CHURCHLAND BLVD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23321-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-761-3921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3921 OLD FARM RD
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23703-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-761-3921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. VERNON LAMONT TILLAGE JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-761-3921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------