Provider Demographics
NPI:1053452953
Name:WAKE FOREST UNIVERSITY STUDENT HEALTH SERVICE
Entity Type:Organization
Organization Name:WAKE FOREST UNIVERSITY STUDENT HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-758-5218
Mailing Address - Street 1:PO BOX 7386
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27109-7386
Mailing Address - Country:US
Mailing Address - Phone:336-758-5218
Mailing Address - Fax:336-758-6054
Practice Address - Street 1:1834 REYNOLDA ROAD
Practice Address - Street 2:MACKIE HEALTH CENTER - REYNOLDS GYM - WINGATE RD. WFU
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106
Practice Address - Country:US
Practice Address - Phone:336-758-5218
Practice Address - Fax:336-758-6054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health