Provider Demographics
NPI:1063408193
Name:SALEM HOUSE OF WINSTON-SALEM, LLC
Entity type:Organization
Organization Name:SALEM HOUSE OF WINSTON-SALEM, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-324-8898
Mailing Address - Street 1:2560 WILLARD RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-5585
Mailing Address - Country:US
Mailing Address - Phone:336-650-0699
Mailing Address - Fax:336-650-0132
Practice Address - Street 1:2560 WILLARD RD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-5585
Practice Address - Country:US
Practice Address - Phone:336-650-0699
Practice Address - Fax:336-650-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL034074310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805233Medicaid