Provider Demographics
NPI:1962558916
Name:TRIUMPH LLC
Entity type:Organization
Organization Name:TRIUMPH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TALESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-256-0824
Mailing Address - Street 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:207 10TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:N. WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-4153
Practice Address - Country:US
Practice Address - Phone:336-667-1440
Practice Address - Fax:336-667-1489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIUMPH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103TC0700X, 1041C0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905083Medicaid
NC5905083Medicaid
NC2335621Medicare PIN
NC2335621AMedicare PIN