Healthcare Provider Details

I. General information

NPI: 1184809279
Provider Name (Legal Business Name): TAR RIVER LTC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 US HIGHWAY 64 E
PLYMOUTH NC
27962-9215
US

IV. Provider business mailing address

1084 US HIGHWAY 64 E
PLYMOUTH NC
27962-9215
US

V. Phone/Fax

Practice location:
  • Phone: 252-793-2100
  • Fax: 252-793-1243
Mailing address:
  • Phone: 252-793-2100
  • Fax: 252-793-1243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH0419
License Number StateNC

VIII. Authorized Official

Name: NORWOOD RANDOLPH UZZELL
Title or Position: PRESIDENT
Credential:
Phone: 252-523-9094