Organization
EXECUTIVE IMAGE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANA B GOOLSBY (PRESIDENT/CEO)
(336) 918-6328
Entity
Organization
Contact information
Practice address
470 W HANES MILL RD, SUITE 107, WINSTON SALEM, NC 27105-9102
(336) 918-6328
(800) 840-4241
Mailing address
470 W HANES MILL RD, SUITE 107, WINSTON SALEM, NC 27105-9102
(336) 918-6328
(800) 840-4241
Taxonomy
Speciality
Code
Description
License number
State
293D00000X
Physiological Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2530321
MEDICARE PTAN
—
05
—
3409805
—
NC
Enumeration date
01/20/2015
Last updated
01/20/2015
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