Healthcare Provider Details

I. General information

NPI: 1700905221
Provider Name (Legal Business Name): TRACEY L JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 THORNTON CT
GREENSBORO NC
27407-1429
US

IV. Provider business mailing address

115 THORNTON CT
GREENSBORO NC
27407-1429
US

V. Phone/Fax

Practice location:
  • Phone: 336-323-2718
  • Fax:
Mailing address:
  • Phone: 336-323-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number041771
License Number StateNC

VIII. Authorized Official

Name: MISS TRACEY L JOHNSON
Title or Position: OWNEROPERATOR
Credential:
Phone: 336-323-2718