Provider Demographics
NPI:1407000540
Name:MILLER STREET DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Entity Type:Organization
Organization Name:MILLER STREET DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Other - Org Name:MILLER STREET 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 1:120 MILLER ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2509
Practice Address - Country:US
Practice Address - Phone:336-721-4801
Practice Address - Fax:336-721-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3402667Medicaid
NC34-2667Medicare PIN