Provider Demographics
NPI:1124250733
Name:NATCHEZ TRACE GROUP HOME, INC.
Entity type:Organization
Organization Name:NATCHEZ TRACE GROUP HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DE KONING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-796-2039
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:HOHENWALD
Mailing Address - State:TN
Mailing Address - Zip Code:38462-0309
Mailing Address - Country:US
Mailing Address - Phone:931-796-2039
Mailing Address - Fax:931-796-5289
Practice Address - Street 1:116 KITTRELL ST
Practice Address - Street 2:
Practice Address - City:HOHENWALD
Practice Address - State:TN
Practice Address - Zip Code:38462-1363
Practice Address - Country:US
Practice Address - Phone:931-796-4400
Practice Address - Fax:931-796-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000003374323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility