Healthcare Provider Details

I. General information

NPI: 1558973685
Provider Name (Legal Business Name): RODERICK KIRBY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 ARDMORE MNR
WINSTON SALEM NC
27103-4801
US

IV. Provider business mailing address

2429 ARDMORE MNR
WINSTON SALEM NC
27103-4801
US

V. Phone/Fax

Practice location:
  • Phone: 336-776-8176
  • Fax:
Mailing address:
  • Phone: 336-776-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number2879506
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: