MEDICARE: PIEDMONT WELLNESS GROUP, L.L.C.

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1164655510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIEDMONT WELLNESS GROUP, L.L.C.

Provider Business Mailing Address
First Line	:	3516 VEST MILL RD STE L1
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2979
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3516 VEST MILL RD STE L1
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2979
Country	:	US
Telephone Number	:	336-793-8283
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. D'NODRICK MICHAEL HICKS
Credential	:
Telephone Number	:	336-793-8283

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	09/02/2009

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