Provider Demographics
NPI:1215485024
Name:PIEDMONT TRIAD REGIONAL COUNCIL
Entity type:Organization
Organization Name:PIEDMONT TRIAD REGIONAL COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-904-0300
Mailing Address - Street 1:1398 CARROLLTON CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-3896
Mailing Address - Country:US
Mailing Address - Phone:336-904-0300
Mailing Address - Fax:336-904-0301
Practice Address - Street 1:1398 CARROLLTON CROSSING DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3896
Practice Address - Country:US
Practice Address - Phone:336-904-0300
Practice Address - Fax:336-904-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty