Provider Demographics
NPI:1730229931
Name:TRIAD TELECARE, INC.
Entity type:Organization
Organization Name:TRIAD TELECARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PEARLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-674-6293
Mailing Address - Street 1:1324 COLTRANE MILL RD
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-8020
Mailing Address - Country:US
Mailing Address - Phone:336-674-6293
Mailing Address - Fax:336-647-1692
Practice Address - Street 1:1324 COLTRANE MILL RD
Practice Address - Street 2:
Practice Address - City:RANDLEMAN
Practice Address - State:NC
Practice Address - Zip Code:27317-8020
Practice Address - Country:US
Practice Address - Phone:336-674-6293
Practice Address - Fax:336-647-1692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL076085171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302093Medicaid