Provider Demographics
NPI:1376716811
Name:WINSTON SALEM STATE UNIVERSITY, A. H. RAY STUDENT HEALTH SERVICE
Entity Type:Organization
Organization Name:WINSTON SALEM STATE UNIVERSITY, A. H. RAY STUDENT HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE CHANCELLOR STUDENT AFFAIRS
Authorized Official - Prefix:DR
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-750-3203
Mailing Address - Street 1:601 S MARTIN LUTHER KING JR DR
Mailing Address - Street 2:RM 244, A. H. RAY BUILDING
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27110-0001
Mailing Address - Country:US
Mailing Address - Phone:336-750-3300
Mailing Address - Fax:
Practice Address - Street 1:601 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:RM 244, A. H. RAY BUILDING
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0001
Practice Address - Country:US
Practice Address - Phone:336-750-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC AW 5031 924261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health