1306036470 NPI number — LATRINA DEVONNE WINFORD LPCS

Table of content: LATRINA DEVONNE WINFORD LPCS (NPI 1306036470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306036470 NPI number — LATRINA DEVONNE WINFORD LPCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINFORD
Provider First Name:
LATRINA
Provider Middle Name:
DEVONNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306036470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24551
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27114-4551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-577-6652
Provider Business Mailing Address Fax Number:
336-464-2071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1922 S MARTIN LUTHER KING JR DR
Provider Second Line Business Practice Location Address:
25
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27107-1361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-577-6652
Provider Business Practice Location Address Fax Number:
336-464-2071
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PC1635 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6103689 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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