# EXECUTIVE IMAGE, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1326437989
- **Authorized official:** DIANA B GOOLSBY (PRESIDENT/CEO)
- **Authorized official phone:** (336) 918-6328

## Contact information

- **Practice address:** 470 W HANES MILL RD, SUITE 107, WINSTON SALEM, NC 27105-9102
- **Practice address phone:** (336) 918-6328
- **Practice address fax:** (800) 840-4241
- **Mailing address:** 470 W HANES MILL RD, SUITE 107, WINSTON SALEM, NC 27105-9102
- **Mailing address phone:** (336) 918-6328
- **Mailing address fax:** (800) 840-4241

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 293D00000X | Physiological Laboratory | — | NULL | Yes |

## Other

- **Enumeration date:** 01/20/2015
- **Last updated:** 01/20/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2530321 | MEDICARE PTAN | — |
| 05 | — | 3409805 | — | NC |