Provider Demographics
NPI:1215754775
Name:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Entity type:Organization
Organization Name:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MANAGED HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-713-4944
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-713-0947
Mailing Address - Fax:
Practice Address - Street 1:2755 NC HIGHWAY 66 S
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8533
Practice Address - Country:US
Practice Address - Phone:336-834-3653
Practice Address - Fax:336-886-0098
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty