MEDICARE: LTC HEALTHCARE AT FLORENCE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1881844017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LTC HEALTHCARE AT FLORENCE, INC.

Provider Business Mailing Address
First Line	:	3110 SCOTT CIRCLE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68112
Country	:	US
Telephone Number	:	402-455-6636
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 SCOTT CIRCLE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68112
Country	:	US
Telephone Number	:	402-455-6636
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DOUGLAS K. MITTLEIDER
Credential	:
Telephone Number	:	770-619-0866

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	11/25/2008

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