Provider Demographics
NPI:1063696623
Name:TRISOUTH HEALTH SERVICES INC
Entity type:Organization
Organization Name:TRISOUTH HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSW
Authorized Official - Phone:704-369-4533
Mailing Address - Street 1:PO BOX 242036
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28224-2036
Mailing Address - Country:US
Mailing Address - Phone:704-369-4533
Mailing Address - Fax:
Practice Address - Street 1:1435 AUGUSTA RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4027
Practice Address - Country:US
Practice Address - Phone:704-369-4533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC251E00000XMedicaid
SC251J00000XMedicaid