=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750576997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLTRANES GROUP HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 09/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 REPON ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27407-5536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-299-9757
-----------------------------------------------------
Fax | 336-299-1419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 79113
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27417-9113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-299-9757
-----------------------------------------------------
Fax | 336-299-1419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MS. LATHAY LORRAINE COLTRANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-299-9757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-041-620
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------