Healthcare Provider Details

I. General information

NPI: 1821024274
Provider Name (Legal Business Name): EAGLE PEAK LTC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 CARY ST
ENFIELD NC
27823-1204
US

IV. Provider business mailing address

1435 HIGHWAY 258N
KINSTON NC
28504-7208
US

V. Phone/Fax

Practice location:
  • Phone: 252-445-2111
  • Fax: 252-445-5646
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0037
License Number StateNC

VIII. Authorized Official

Name: MS. GALE BOICE
Title or Position: CFO
Credential:
Phone: 252-523-9094