Provider Demographics
NPI:1518042811
Name:VINTAGE INN OF WILLIAMSTON, LLC
Entity Type:Organization
Organization Name:VINTAGE INN OF WILLIAMSTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:S
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-595-1075
Mailing Address - Street 1:PO BOX 1487
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27285-1487
Mailing Address - Country:US
Mailing Address - Phone:336-595-1075
Mailing Address - Fax:
Practice Address - Street 1:826 EAST BLVD
Practice Address - Street 2:HWY 17 N BYPASS
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2785
Practice Address - Country:US
Practice Address - Phone:252-792-8311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-058-007310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804486Medicaid