Basic Information
| Provider Information | |||||||||
| NPI: | 1205017472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMBRIDGE LTC PARTNERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1621 BUTLER DR | ||||||||
| Address2: | |||||||||
| City: | DIMMITT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8066473117 | ||||||||
| FaxNumber: | 8066475212 | ||||||||
| Practice Location | |||||||||
| Address1: | 1621 BUTLER DR | ||||||||
| Address2: | |||||||||
| City: | DIMMITT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8066473117 | ||||||||
| FaxNumber: | 8066475212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLSON | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | FREDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8324899944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | LNFA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 122924 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004948 | 05 | TX | MEDICAID | 001015400 | 05 | TX | MEDICAID |