Healthcare Provider Details

I. General information

NPI: 1083647069
Provider Name (Legal Business Name): LTC HEALTHCARE OF CONVERSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 MESQUITE PASS
CONVERSE TX
78109-2461
US

IV. Provider business mailing address

925 N POINT PKWY SUITE 440
ALPHARETTA GA
30005-5210
US

V. Phone/Fax

Practice location:
  • Phone: 210-650-0551
  • Fax: 210-650-4472
Mailing address:
  • Phone: 770-619-0866
  • Fax: 770-870-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number115216
License Number StateTX

VIII. Authorized Official

Name: MS. LOUANN ANSTIS
Title or Position: PRIVACY OFFICER
Credential:
Phone: 770-619-0866