Organization
LTC PROVIDER MANAGEMENT CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MYLES EDWARD GOMBERT M.D. (PRESIDENT)
(516) 652-7647
Entity
Organization
Contact information
Practice address
30 WOOD RD, PORT WASHINGTON, NY 11050-2625
(516) 652-7647
(516) 944-2385
Mailing address
30 WOOD RD, PORT WASHINGTON, NY 11050-2625
(516) 652-7647
(516) 944-2385
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
129224
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
45A201
PTAN
NY
Enumeration date
04/14/2016
Last updated
03/27/2017
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