Provider Demographics
NPI:1306120795
Name:ADVANCE REHABILITATION AND NURSING
Entity type:Organization
Organization Name:ADVANCE REHABILITATION AND NURSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:EZEIGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-940-2659
Mailing Address - Street 1:5515 FRESH FIELD LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-6262
Mailing Address - Country:US
Mailing Address - Phone:336-940-2659
Mailing Address - Fax:
Practice Address - Street 1:169 YADKIN VALLEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-8786
Practice Address - Country:US
Practice Address - Phone:336-940-2659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty