Provider Demographics
NPI:1538446893
Name:PINK COYOTE, INC.
Entity type:Organization
Organization Name:PINK COYOTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-748-7002
Mailing Address - Street 1:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:WARTBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37887-1057
Mailing Address - Country:US
Mailing Address - Phone:865-748-7003
Mailing Address - Fax:423-346-1102
Practice Address - Street 1:117 COON HUNTERS RD
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887-3607
Practice Address - Country:US
Practice Address - Phone:865-748-7003
Practice Address - Fax:423-346-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities