1326437989 NPI number — EXECUTIVE IMAGE, INC.

Table of content: (NPI 1326437989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326437989 NPI number — EXECUTIVE IMAGE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXECUTIVE IMAGE, INC.
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:
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:
1326437989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 W HANES MILL RD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27105-9102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-918-6328
Provider Business Mailing Address Fax Number:
800-840-4241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 W HANES MILL RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27105-9102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-918-6328
Provider Business Practice Location Address Fax Number:
800-840-4241
Provider Enumeration Date:
01/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GOOLSBY
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
336-918-6328

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3409805 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2530321 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com