MEDICARE: RJR KALLI, 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1578103081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RJR KALLI, LLC

Provider Business Mailing Address
First Line	:	1114 ELIZABETH ST
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27530-1940
Country	:	US
Telephone Number	:	919-750-7195
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 SAINT GEORGE SQUARE CT STE 312
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-1368
Country	:	US
Telephone Number	:	469-289-1814
Fax Number	:

Authorized Official
Title or Position	:	AGENCY DIRECTOR
Name	:	KEITH PETEN
Credential	:
Telephone Number	:	919-750-7195

Provider Enumeration Date	:	01/13/2020
Last Update Date	:	01/13/2020

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