Basic Information
| Provider Information | |||||||||
| NPI: | 1386187524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLUTE LTC PARTNERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 E PLANTATION DR | ||||||||
| Address2: | |||||||||
| City: | CLUTE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775315719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792654221 | ||||||||
| FaxNumber: | 9792657348 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 E PLANTATION DR | ||||||||
| Address2: | |||||||||
| City: | CLUTE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775315719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792654221 | ||||||||
| FaxNumber: | 9792657348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2016 | ||||||||
| LastUpdateDate: | 01/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLSON | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | FREDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8324899944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 675234 | TX | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 001028430 | TX | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 4340 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001028430 | 05 | TX | MEDICAID | 4340 | 05 | TX | MEDICAID |