Healthcare Provider Details

I. General information

NPI: 1750317897
Provider Name (Legal Business Name): TAR RIVER LTC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 LOVERS LN
WASHINGTON NC
27889-3436
US

IV. Provider business mailing address

PO BOX 398
WASHINGTON NC
27889-0398
US

V. Phone/Fax

Practice location:
  • Phone: 252-975-1636
  • Fax: 252-975-5960
Mailing address:
  • Phone: 252-975-1636
  • Fax: 252-975-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0345
License Number StateNC

VIII. Authorized Official

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