Basic Information
| Provider Information | |||||||||
| NPI: | 1306840251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEECHCENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 CHARLOIS BLVD. | ||||||||
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| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250454 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 CHARLOIS BLVD. | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271071521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 08/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | BATES | ||||||||
| AuthorizedOfficialFirstName: | JERI | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, COO | ||||||||
| AuthorizedOfficialTelephone: | 3367250222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 740272C | 05 | NC | MEDICAID | 0272C | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER |