Provider Demographics
NPI:1720243363
Name:WINSTON SALEM INDUSTRIES FOR THE BLIND
Entity Type:Organization
Organization Name:WINSTON SALEM INDUSTRIES FOR THE BLIND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICAL OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:ABO
Authorized Official - Phone:336-245-5628
Mailing Address - Street 1:7730 N POINT BLVD
Mailing Address - Street 2:OPTICAL DISPENSARY
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3310
Mailing Address - Country:US
Mailing Address - Phone:336-759-0551
Mailing Address - Fax:336-759-7778
Practice Address - Street 1:7730 N POINT BLVD
Practice Address - Street 2:OPTICAL DISPENSARY
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3310
Practice Address - Country:US
Practice Address - Phone:336-759-2257
Practice Address - Fax:336-759-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802011Medicaid