1407000540 NPI number — MILLER STREET DIALYSIS CENTER OF WAKE FOREST UNIVERSITY

Table of content: (NPI 1407000540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407000540 NPI number — MILLER STREET DIALYSIS CENTER OF WAKE FOREST UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLER STREET DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MILLER STREET DIALYSIS CENTER
Provider Other Organization Name Type Code:
3
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:
1407000540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7710
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31793-7710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-387-3527
Provider Business Mailing Address Fax Number:
229-386-2149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 MILLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-721-4801
Provider Business Practice Location Address Fax Number:
336-721-4861
Provider Enumeration Date:
11/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HALES
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ASSISTANT TREASURER
Authorized Official Telephone Number:
336-716-3003

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3402667 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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