Healthcare Provider Details

I. General information

NPI: 1114904141
Provider Name (Legal Business Name): SALEM KIDNEY CENTER OF WAKE FOREST UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 BOULDER PARK CT
WINSTON-SALEM NC
27101-4776
US

IV. Provider business mailing address

PO BOX 7710
TIFTON GA
31793-7710
US

V. Phone/Fax

Practice location:
  • Phone: 336-761-8808
  • Fax: 336-761-8864
Mailing address:
  • Phone: 229-387-3527
  • Fax: 229-386-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number StateNC

VIII. Authorized Official

Name: TERRY L HALES JR.
Title or Position: ASSISTANT TREASURER
Credential:
Phone: 336-716-3003