1205979580 NPI number — LIBERTY HEALTHCARE GROUP LLC

Table of content: (NPI 1205979580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205979580 NPI number — LIBERTY HEALTHCARE GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY HEALTHCARE GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THREE RIVERS HEALTH & REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205979580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2334 S 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-5502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-332-8155
Provider Business Mailing Address Fax Number:
910-642-8537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1403 CONNER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27983-8514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-794-4441
Provider Business Practice Location Address Fax Number:
252-794-2800
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CALCUTT
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
910-332-1793

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0522 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 343601A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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