Healthcare Provider Details

I. General information

NPI: 1891740544
Provider Name (Legal Business Name): LIBERTY HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 TRAMWAY RD
SANFORD NC
27332-7142
US

IV. Provider business mailing address

2334 SOUTH 41ST STREET LIBERTY HEALTHCARE MANAGEMENT INC
WILMINGTON NC
28403
US

V. Phone/Fax

Practice location:
  • Phone: 919-775-5404
  • Fax: 919-775-9468
Mailing address:
  • Phone: 910-332-1777
  • Fax: 910-815-3114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0285
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberNH0285
License Number StateNC

VIII. Authorized Official

Name: MR. JOE CALCUTT
Title or Position: CFO
Credential:
Phone: 910-332-1793