MEDICARE: SALEM HOUSE OF WINSTON-SALEM, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	HAL034074	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063408193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALEM HOUSE OF WINSTON-SALEM, LLC

Provider Business Mailing Address
First Line	:	2560 WILLARD RD
Second Line	:
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27107-5585
Country	:	US
Telephone Number	:	336-650-0699
Fax Number	:	336-650-0132

Provider Business Practice Location Address
First Line	:	2560 WILLARD RD
Second Line	:
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27107-5585
Country	:	US
Telephone Number	:	336-650-0699
Fax Number	:	336-650-0132

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MRS. TINA A HALLMAN
Credential	:
Telephone Number	:	828-324-8898

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	08/22/2020

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