Basic Information
Provider Information | |||||||||
NPI: | 1518042811 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VINTAGE INN OF WILLIAMSTON, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1487 | ||||||||
Address2: |   | ||||||||
City: | KERNERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 272851487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3365951075 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 826 EAST BLVD | ||||||||
Address2: | HWY 17 N BYPASS | ||||||||
City: | WILLIAMSTON | ||||||||
State: | NC | ||||||||
PostalCode: | 278922785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527928311 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIERCE | ||||||||
AuthorizedOfficialFirstName: | GUY | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 3365951075 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | HAL-058-007 | NC | X |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 310400000X | HAL-058-007 | NC | X |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 7804486 | 05 | NC |   | MEDICAID |