Basic Information
| Provider Information | |||||||||
| NPI: | 1942346903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT STONE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25866 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271145866 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 557 BROOKDALE DR | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286774107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048735661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAUSER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3367142500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QL0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Lithotripsy |
ID Information
| ID | Type | State | Issuer | Description | 890274M | 05 | NC | MEDICAID |