Provider Demographics
NPI:1528035961
Name:DAVIS LONG TERM CARE GROUP INC
Entity Type:Organization
Organization Name:DAVIS LONG TERM CARE GROUP INC
Other - Org Name:CAPITOL CITY MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:207-594-4990
Mailing Address - Street 1:58 PARK ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2862
Mailing Address - Country:US
Mailing Address - Phone:207-594-4990
Mailing Address - Fax:207-594-4974
Practice Address - Street 1:313 STATE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7037
Practice Address - Country:US
Practice Address - Phone:207-622-6823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME113410002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility