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General NPI Number Information
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NPI Number | 1437324902
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Entity Type | Organization
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Legal Business Name | COLTRANE'S GROUP HOME
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Dates
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Enumeration Date | 04/25/2008
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Last Update Date | 04/25/2008
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Provider Practice Location Address
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Address Line | 3811 REPON ST
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City | GREENSBORO
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State | NC
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Zip | 27407-5536
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Country | US
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Telephone | 336-299-1419
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 79113
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City | GREENSBORO
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State | NC
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Zip | 27417-9113
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Country | US
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Telephone | 336-299-1419
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | LATHAY COLTRANE
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Credential |
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Telephone | 336-669-2819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | MHL-041-620
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License Number State | NC
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