Provider Demographics
NPI:1629287073
Name:ORANGE GROVE CENTER, INC
Entity Type:Organization
Organization Name:ORANGE GROVE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-629-1451
Mailing Address - Street 1:615 DERBY ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1632
Mailing Address - Country:US
Mailing Address - Phone:423-629-1451
Mailing Address - Fax:423-624-1294
Practice Address - Street 1:4403 COMET TRL
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4313
Practice Address - Country:US
Practice Address - Phone:423-629-1451
Practice Address - Fax:423-624-1294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3230961537315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447113Medicaid