Basic Information
| Provider Information | |||||||||
| NPI: | 1750558607 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LTC INFORMATION SYSTEMS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINTERS ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 E LIVE OAK ST | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764461914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2544452517 | ||||||||
| FaxNumber: | 2544453960 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 E TRUETT ST | ||||||||
| Address2: | |||||||||
| City: | WINTERS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795674527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3257545083 | ||||||||
| FaxNumber: | 3257544570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 11/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | BOBBIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | V. PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2544452517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 001016273 | 05 | TX | MEDICAID | 001016272 | 05 | TX | MEDICAID |