Provider Demographics
NPI:1417902578
Name:LTC MANAGEMENT SUCS
Entity Type:Organization
Organization Name:LTC MANAGEMENT SUCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLSTED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-448-3705
Mailing Address - Street 1:14800 ST. MARY'S LANE STE 175
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079
Mailing Address - Country:US
Mailing Address - Phone:832-448-3705
Mailing Address - Fax:
Practice Address - Street 1:14800 ST. MARY'S LANE STE 175
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079
Practice Address - Country:US
Practice Address - Phone:832-448-3705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332BP3500X332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4841190002Medicare ID - Type Unspecified