Healthcare Provider Details

I. General information

NPI: 1194586115
Provider Name (Legal Business Name): ELEGANT PROFILE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4622 COUNTRY CLUB RD STE 100
WINSTON SALEM NC
27104-3770
US

IV. Provider business mailing address

4622 COUNTRY CLUB RD STE 100
WINSTON SALEM NC
27104-3770
US

V. Phone/Fax

Practice location:
  • Phone: 336-331-3480
  • Fax: 336-793-1218
Mailing address:
  • Phone: 336-331-3480
  • Fax: 336-793-1218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JUSTINE JUCHTER
Title or Position: VICE PRESIDENT
Credential:
Phone: 336-331-3480