1750317897 NPI number — TAR RIVER LTC GROUP, LLC

Table of content: (NPI 1750317897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750317897 NPI number — TAR RIVER LTC GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAR RIVER LTC 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:
RIVER TRACE NURSING AND 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:
1750317897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 398
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27889-0398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-975-1636
Provider Business Mailing Address Fax Number:
252-975-5960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 LOVERS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27889-3436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-975-1636
Provider Business Practice Location Address Fax Number:
252-975-5960
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCDANIEL
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
252-523-9094

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0345 , 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: 3425215 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3415215 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7801167 . This is a "MEDICAID ADULT CARE #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0089L . This is a "BC/BS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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