Provider Demographics
NPI:1457528788
Name:ECHO TRAIL GROUP HOME
Entity Type:Organization
Organization Name:ECHO TRAIL GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAHOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-906-8893
Mailing Address - Street 1:3634 VEST MILL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2910
Mailing Address - Country:US
Mailing Address - Phone:704-547-1900
Mailing Address - Fax:
Practice Address - Street 1:1930 ECHO TRL
Practice Address - Street 2:
Practice Address - City:PFAFFTOWN
Practice Address - State:NC
Practice Address - Zip Code:27040-9518
Practice Address - Country:US
Practice Address - Phone:336-924-6649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW-LITE LIVING CHOICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604265Medicaid