1750317897 NPI number — TAR RIVER LTC GROUP, LLC

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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