Basic Information
Provider Information | |||||||||
NPI: | 1598361891 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOTAL LONGTERM CARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INNOVAGE COLORADO PACE THORNTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8950 E LOWRY BLVD | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802307030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039127193 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 445 E 124TH AVE | ||||||||
Address2: |   | ||||||||
City: | THORNTON | ||||||||
State: | CO | ||||||||
PostalCode: | 802412402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033271189 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2020 | ||||||||
LastUpdateDate: | 10/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WASHINGTON | ||||||||
AuthorizedOfficialFirstName: | GAYLE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 3039127193 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TOTAL LONGTERM CARE, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X |   |   | Y |   | Agencies | PACE Provider Organization |   |
ID Information
ID | Type | State | Issuer | Description | 51175045 | 05 | CO |   | MEDICAID |