Healthcare Provider Details

I. General information

NPI: 1265575740
Provider Name (Legal Business Name): LIBERTY HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 BOONE STATION DR
BURLINGTON NC
27215
US

IV. Provider business mailing address

2334 S 41ST ST
WILMINGTON NC
28403-5502
US

V. Phone/Fax

Practice location:
  • Phone: 336-586-9850
  • Fax: 336-586-9811
Mailing address:
  • Phone: 910-815-3122
  • Fax: 910-642-8537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberNH0588
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberNH0588
License Number StateNC

VIII. Authorized Official

Name: JOE CALCUTT
Title or Position: CFO
Credential:
Phone: 910-815-1793