Healthcare Provider Details

I. General information

NPI: 1669449542
Provider Name (Legal Business Name): TRC OF LOUISBURG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 SMOKETREE WAY
LOUISBURG NC
27549-2117
US

IV. Provider business mailing address

PO BOX 589
LOUISBURG NC
27549-0589
US

V. Phone/Fax

Practice location:
  • Phone: 919-496-6084
  • Fax: 919-496-5458
Mailing address:
  • Phone: 919-496-6084
  • Fax: 919-496-5458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-035-003
License Number StateNC

VIII. Authorized Official

Name: MR. NICK ELLEDGE
Title or Position: VICE PRESIDENT
Credential:
Phone: 336-679-8852