Provider Demographics
NPI:1912902230
Name:LUTHERAN HOME - WINSTON-SALEM, INC.
Entity Type:Organization
Organization Name:LUTHERAN HOME - WINSTON-SALEM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:GOINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-637-2870
Mailing Address - Street 1:5350 OLD WALKERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-2060
Mailing Address - Country:US
Mailing Address - Phone:336-595-2166
Mailing Address - Fax:336-595-2169
Practice Address - Street 1:5350 OLD WALKERTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-2060
Practice Address - Country:US
Practice Address - Phone:336-595-2166
Practice Address - Fax:336-595-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0058314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3415088Medicaid
NC3416006Medicaid
NC3415088Medicaid