MEDICARE: ENDWELL HOMES 1 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1083017230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDWELL HOMES 1 LLC

Provider Business Mailing Address
First Line	:	4403 PAULA DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-6835
Country	:	US
Telephone Number	:	757-513-8987
Fax Number	:

Provider Business Practice Location Address
First Line	:	4403 PAULA DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-6835
Country	:	US
Telephone Number	:	757-513-8987
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANTHONY I OKAFOR
Credential	:
Telephone Number	:	757-513-8987

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	10/02/2014

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Directions to “ENDWELL HOMES 1 LLC ” Practice Location

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