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General NPI Number Information
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NPI Number | 1376714816
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Entity Type | Organization
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Legal Business Name | WARREN STACKS MD
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Dates
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Enumeration Date | 03/12/2008
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Last Update Date | 04/08/2010
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Provider Practice Location Address
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Address Line | 1400 WESTGATE CENTER DR STE 140
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City | WINSTON SALEM
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State | NC
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Zip | 27103-3104
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Country | US
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Telephone | 336-659-9440
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Fax | 336-659-9845
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Provider Business Mailing Address
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Address Line | PO BOX 30249
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City | WINSTON SALEM
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State | NC
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Zip | 27130-0249
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Country | US
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Telephone | 336-659-9440
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Fax | 336-659-9845
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Authorized Official
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Title or Position | OWNER
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Name | DR. WARREN STACKS
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Credential | MD
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Telephone | 336-659-9440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 9401498
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License Number State | NC
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