Healthcare Provider Details

I. General information

NPI: 1841165198
Provider Name (Legal Business Name): WHIT RAVEN ADULT CARE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 SNEAD RD
WINSTON SALEM NC
27103-6830
US

IV. Provider business mailing address

203 SNEAD RD
WINSTON SALEM NC
27103-6830
US

V. Phone/Fax

Practice location:
  • Phone: 336-293-6664
  • Fax:
Mailing address:
  • Phone: 336-293-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: RODERICK GIST
Title or Position: OWNER/OPERATOR
Credential:
Phone: 336-287-8789