Provider Demographics
NPI:1417137340
Name:WINSTON SALEM HEALTHCARE LLC
Entity Type:Organization
Organization Name:WINSTON SALEM HEALTHCARE LLC
Other - Org Name:GRACE HEALTHCARE OF WINSTON SALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLARK DANKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:423-308-1845
Mailing Address - Street 1:1900 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4220
Mailing Address - Country:US
Mailing Address - Phone:336-724-2821
Mailing Address - Fax:336-725-8314
Practice Address - Street 1:1900 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4220
Practice Address - Country:US
Practice Address - Phone:336-724-2821
Practice Address - Fax:336-725-8314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC923570314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3416540Medicaid
NC0345092Medicaid
NC0345092Medicaid