Healthcare Provider Details

I. General information

NPI: 1285660787
Provider Name (Legal Business Name): TAR RIVER LTC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 04/10/2017
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 TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberNH0419
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0419
License Number StateNC

VIII. Authorized Official

Name: MS. KAREN G MCDANIEL
Title or Position: PRESIDENT
Credential:
Phone: 252-523-9094