Provider Demographics
NPI:1922038082
Name:KEYSTONE WSNC, LLC
Entity Type:Organization
Organization Name:KEYSTONE WSNC, LLC
Other - Org Name:OLD VINEYARD BEHAVIORAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:FILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-768-3300
Mailing Address - Street 1:3637 OLD VINEYARD RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4842
Mailing Address - Country:US
Mailing Address - Phone:336-794-3550
Mailing Address - Fax:336-794-3545
Practice Address - Street 1:3637 OLD VINEYARD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4842
Practice Address - Country:US
Practice Address - Phone:336-794-3550
Practice Address - Fax:336-794-3545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHH0188283Q00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404007Medicaid
NC3404520Medicaid
NC3404520Medicaid