Provider Demographics
NPI:1669871406
Name:DAVIS LONG TERM CARE GROUP INC
Entity type:Organization
Organization Name:DAVIS LONG TERM CARE GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-594-4990
Mailing Address - Street 1:18 TALBOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:64 LISBON ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ME
Practice Address - Zip Code:04250-6017
Practice Address - Country:US
Practice Address - Phone:207-353-4318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMETPID005598Medicaid