Provider Demographics
NPI:1578530911
Name:DAVIS LONG TERM CARE GROUP INC
Entity Type:Organization
Organization Name:DAVIS LONG TERM CARE GROUP INC
Other - Org Name:DAVIS ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLOUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:207-594-4990
Mailing Address - Street 1:18 TALBOT AVE
Mailing Address - Street 2:
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 1:96 STACKPOLE DRIVE
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-1115
Practice Address - Country:US
Practice Address - Phone:207-255-6611
Practice Address - Fax:207-255-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME121180000310400000X
MEPND665310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMETPID002096Medicaid