MEDICARE: TAR RIVER LTC GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385H00000X	Respite Care	NH0419	NC
2	314000000X	Skilled Nursing Facility	NH0419	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0085E	OTHER	NC	BC/BS OF NC
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285660787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAR RIVER LTC GROUP, LLC

Provider Business Mailing Address
First Line	:	1084 US HIGHWAY 64 E
Second Line	:
City	:	PLYMOUTH
State	:	NC
Zip	:	27962-9215
Country	:	US
Telephone Number	:	252-793-2100
Fax Number	:	252-793-1243

Provider Business Practice Location Address
First Line	:	1084 US HIGHWAY 64 E
Second Line	:
City	:	PLYMOUTH
State	:	NC
Zip	:	27962-9215
Country	:	US
Telephone Number	:	252-793-2100
Fax Number	:	252-793-1243

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. KAREN G MCDANIEL
Credential	:
Telephone Number	:	252-523-9094

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	04/10/2017

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Directions to “TAR RIVER LTC GROUP, LLC ” Practice Location

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