Provider Demographics
NPI:1366594715
Name:COLTRANES GROUP HOME
Entity type:Organization
Organization Name:COLTRANES GROUP HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LATHAY
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:COLTRANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-299-9757
Mailing Address - Street 1:3811 REPON ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-5536
Mailing Address - Country:US
Mailing Address - Phone:336-299-9757
Mailing Address - Fax:336-299-1419
Practice Address - Street 1:3811 REPON ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-5536
Practice Address - Country:US
Practice Address - Phone:336-299-9757
Practice Address - Fax:336-299-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408773Medicaid
NC7804354Medicaid