1518042811 NPI number — VINTAGE INN OF WILLIAMSTON, LLC

Table of content: (NPI 1518042811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518042811 NPI number — VINTAGE INN OF WILLIAMSTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINTAGE INN OF WILLIAMSTON, LLC
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:
1518042811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERNERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27285-1487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-595-1075
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 EAST BLVD
Provider Second Line Business Practice Location Address:
HWY 17 N BYPASS
Provider Business Practice Location Address City Name:
WILLIAMSTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27892-2785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-792-8311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
GUY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
336-595-1075

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  HAL-058-007 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 311500000X , with the licence number: HAL-058-007 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 7804486 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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