Basic Information
| Provider Information | |||||||||
| NPI: | 1396332946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOTAL LONGTERM CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8950 E LOWRY BLVD | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802307030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039127193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 W NORTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195530400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2020 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | WASHINGTON | ||||||||
| AuthorizedOfficialFirstName: | GAYLE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3039127193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOTAL LONG TERM CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | Y | Agencies | PACE Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | O1336363 | 05 | CO | MEDICAID |