Healthcare Provider Details

I. General information

NPI: 1568050573
Provider Name (Legal Business Name): ULTIMATE SACRIFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 PREMIER PARK LN
WINSTON SALEM NC
27105-6306
US

IV. Provider business mailing address

200 GREENSBORO RD
HIGH POINT NC
27260-3456
US

V. Phone/Fax

Practice location:
  • Phone: 336-254-5796
  • Fax:
Mailing address:
  • Phone: 336-875-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: JASMINE TIARA HOYLE
Title or Position: CEO
Credential:
Phone: 336-254-5796