Healthcare Provider Details

I. General information

NPI: 1063457562
Provider Name (Legal Business Name): GERIATRIC HEALTHCARE SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 HUNTSCROFT LN
WINSTON SALEM NC
27106-4777
US

IV. Provider business mailing address

PO BOX 24416
WINSTON SALEM NC
27114-4416
US

V. Phone/Fax

Practice location:
  • Phone: 336-245-2764
  • Fax: 336-245-2765
Mailing address:
  • Phone: 336-245-2764
  • Fax: 336-923-2189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLOS M IRUELA
Title or Position: OFFICE MANAGER
Credential:
Phone: 336-245-2764