Provider Demographics
NPI:1609163138
Name:CMT HOME HEALTH AGENCY
Entity Type:Organization
Organization Name:CMT HOME HEALTH AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTEE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:704-262-6914
Mailing Address - Street 1:2604 S RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2852
Mailing Address - Country:US
Mailing Address - Phone:704-262-6914
Mailing Address - Fax:800-886-8442
Practice Address - Street 1:2604 S RIDGE AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2852
Practice Address - Country:US
Practice Address - Phone:704-262-6914
Practice Address - Fax:800-886-8442
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CABARRUS-MECKLENBURG TRANSPORT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251T00000X, 253Z00000X
NC253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418940Medicaid