Provider Demographics
NPI:1912535097
Name:KWEEN5464 CORPORATION
Entity Type:Organization
Organization Name:KWEEN5464 CORPORATION
Other - Org Name:AT HOME ELDERCARE OF WINSTON SALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIGREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-582-9156
Mailing Address - Street 1:PO BOX 561
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0561
Mailing Address - Country:US
Mailing Address - Phone:336-582-9156
Mailing Address - Fax:888-682-1348
Practice Address - Street 1:1826 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4606
Practice Address - Country:US
Practice Address - Phone:336-582-9156
Practice Address - Fax:888-682-1348
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KWEEN5464 CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-01
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care