Healthcare Provider Details

I. General information

NPI: 1922038082
Provider Name (Legal Business Name): KEYSTONE WSNC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3637 OLD VINEYARD RD
WINSTON SALEM NC
27104-4842
US

IV. Provider business mailing address

3637 OLD VINEYARD RD
WINSTON SALEM NC
27104-4842
US

V. Phone/Fax

Practice location:
  • Phone: 336-794-3550
  • Fax: 336-794-3545
Mailing address:
  • Phone: 336-794-3550
  • Fax: 336-794-3545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberMHH0188
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberMHH0188
License Number StateNC

VIII. Authorized Official

Name: STEVE FILTON
Title or Position: SR VP CFO
Credential:
Phone: 610-768-3300