Healthcare Provider Details

I. General information

NPI: 1548770423
Provider Name (Legal Business Name): LIBERTY HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N FODALE AVE
SOUTHPORT NC
28461
US

IV. Provider business mailing address

44 MCNEILL PLZ
WHITEVILLE NC
28472-8602
US

V. Phone/Fax

Practice location:
  • Phone: 910-457-9581
  • Fax:
Mailing address:
  • Phone: 910-642-0224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH V CALCUTT
Title or Position: CFO
Credential:
Phone: 910-815-3122