Healthcare Provider Details

I. General information

NPI: 1356617419
Provider Name (Legal Business Name): HEALTHTIQUE WINSTON SALEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W 1ST ST
WINSTON SALEM NC
27104-4220
US

IV. Provider business mailing address

46 3RD ST NW
HICKORY NC
28601-6135
US

V. Phone/Fax

Practice location:
  • Phone: 336-724-2821
  • Fax: 336-725-8314
Mailing address:
  • Phone: 828-322-8171
  • Fax: 828-322-3704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL T. JONES
Title or Position: MANAGER
Credential:
Phone: 770-630-0900