Healthcare Provider Details

I. General information

NPI: 1164230017
Provider Name (Legal Business Name): 511 WINDMILL STREET OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 WINDMILL ST
WALNUT COVE NC
27052-7706
US

IV. Provider business mailing address

511 WINDMILL ST
WALNUT COVE NC
27052-7706
US

V. Phone/Fax

Practice location:
  • Phone: 336-491-4353
  • Fax: 336-591-7659
Mailing address:
  • Phone: 336-491-4353
  • Fax: 336-591-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY HOBACK
Title or Position: MANAGER
Credential:
Phone: 770-698-9040