Provider Demographics
NPI:1578103081
Name:RJR KALLI, LLC
Entity Type:Organization
Organization Name:RJR KALLI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-750-7195
Mailing Address - Street 1:1114 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-1940
Mailing Address - Country:US
Mailing Address - Phone:919-750-7195
Mailing Address - Fax:
Practice Address - Street 1:615 SAINT GEORGE SQUARE CT STE 312
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1368
Practice Address - Country:US
Practice Address - Phone:469-289-1814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RJR KALLI, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care