Provider Demographics
NPI:1134106198
Name:LAKE NORMAN DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Entity Type:Organization
Organization Name:LAKE NORMAN DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Other - Org Name:LAKE NORMAN DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:336-716-3003
Mailing Address - Street 1:PO BOX 7710
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-7710
Mailing Address - Country:US
Mailing Address - Phone:229-387-3527
Mailing Address - Fax:229-386-2149
Practice Address - Street 1:164 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5537
Practice Address - Country:US
Practice Address - Phone:704-799-1860
Practice Address - Fax:704-799-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3402606Medicaid
NC00060OtherBCBS-NC
NC34-2606Medicare PIN