Healthcare Provider Details

I. General information

NPI: 1518042811
Provider Name (Legal Business Name): VINTAGE INN OF WILLIAMSTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 EAST BLVD HWY 17 N BYPASS
WILLIAMSTON NC
27892-2785
US

IV. Provider business mailing address

PO BOX 1487
KERNERSVILLE NC
27285-1487
US

V. Phone/Fax

Practice location:
  • Phone: 252-792-8311
  • Fax:
Mailing address:
  • Phone: 336-595-1075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL-058-007
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberHAL-058-007
License Number StateNC

VIII. Authorized Official

Name: GUY S PIERCE
Title or Position: MANAGING MEMBER
Credential:
Phone: 336-595-1075