Provider Demographics
NPI:1144356379
Name:WINSTON SALEM HOLDINGS LLC
Entity type:Organization
Organization Name:WINSTON SALEM HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-738-3046
Mailing Address - Street 1:2900 REYNOLDS PARK RD
Mailing Address - Street 2:PO BOX 12937
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1653
Mailing Address - Country:US
Mailing Address - Phone:336-785-0050
Mailing Address - Fax:336-784-6187
Practice Address - Street 1:2900 REYNOLDS PARK RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-1653
Practice Address - Country:US
Practice Address - Phone:336-785-0050
Practice Address - Fax:336-784-6187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL034079310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805586Medicaid