Provider Demographics
NPI:1346694502
Name:LTC PROVIDER MANAGEMENT CORP
Entity Type:Organization
Organization Name:LTC PROVIDER MANAGEMENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GOMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-652-7647
Mailing Address - Street 1:30 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2625
Mailing Address - Country:US
Mailing Address - Phone:516-652-7647
Mailing Address - Fax:516-944-2385
Practice Address - Street 1:30 WOOD RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2625
Practice Address - Country:US
Practice Address - Phone:516-652-7647
Practice Address - Fax:516-944-2385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129224314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY45A201OtherPTAN