Healthcare Provider Details

I. General information

NPI: 1275752230
Provider Name (Legal Business Name): COLTRANE LIFE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 CORBAN AVE SE
CONCORD NC
28025-2710
US

IV. Provider business mailing address

321 CORBAN AVE SE
CONCORD NC
28025-2710
US

V. Phone/Fax

Practice location:
  • Phone: 704-788-1215
  • Fax: 704-788-1209
Mailing address:
  • Phone: 704-788-1215
  • Fax: 704-788-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNC

VIII. Authorized Official

Name: MRS. SUSAN CAUDLE
Title or Position: ADMINISTRATIVE FINANCIAL ASSISTANT
Credential:
Phone: 704-788-1215