Healthcare Provider Details

I. General information

NPI: 1801873831
Provider Name (Legal Business Name): PIEDMONT DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 COTTON ST
WINSTON SALEM NC
27101-5064
US

IV. Provider business mailing address

PO BOX 7350
TIFTON GA
31793-7350
US

V. Phone/Fax

Practice location:
  • Phone: 336-721-1360
  • Fax: 336-773-0716
Mailing address:
  • Phone: 229-387-3528
  • Fax: 229-386-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number StateNC

VIII. Authorized Official

Name: MS. KIMBERLY AGEE-CLARK JOHNSON
Title or Position: CREDENTIALING COORD.
Credential: MBA
Phone: 229-387-3528