Provider Demographics
NPI:1700905221
Name:TRACEY L JOHNSON
Entity Type:Organization
Organization Name:TRACEY L JOHNSON
Other - Org Name:HAMPTON GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNEROPERATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-323-2718
Mailing Address - Street 1:115 THORNTON CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1429
Mailing Address - Country:US
Mailing Address - Phone:336-323-2718
Mailing Address - Fax:
Practice Address - Street 1:115 THORNTON CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1429
Practice Address - Country:US
Practice Address - Phone:336-323-2718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0417713104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805468Medicare ID - Type Unspecified