Provider Demographics
NPI:1063958338
Name:LONGMONT TC, LLC
Entity type:Organization
Organization Name:LONGMONT TC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-899-4401
Mailing Address - Street 1:1500 WATERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6011
Mailing Address - Country:US
Mailing Address - Phone:972-899-4401
Mailing Address - Fax:972-899-4806
Practice Address - Street 1:1960 SOUTH FORDHAM ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503
Practice Address - Country:US
Practice Address - Phone:972-899-4401
Practice Address - Fax:972-899-4806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-11
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility