Healthcare Provider Details

I. General information

NPI: 1124250733
Provider Name (Legal Business Name): NATCHEZ TRACE GROUP HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 KITTRELL ST
HOHENWALD TN
38462-1363
US

IV. Provider business mailing address

PO BOX 309
HOHENWALD TN
38462-0309
US

V. Phone/Fax

Practice location:
  • Phone: 931-796-4400
  • Fax: 931-796-4492
Mailing address:
  • Phone: 931-796-2039
  • Fax: 931-796-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberL000000003374
License Number StateTN

VIII. Authorized Official

Name: MR. VINCENT DE KONING
Title or Position: CEO
Credential:
Phone: 931-796-2039