MEDICARE: LIBERTY HEALTHCARE GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	NH0469	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366585796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY HEALTHCARE GROUP LLC

Provider Business Mailing Address
First Line	:	2334 S 41ST ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-5502
Country	:	US
Telephone Number	:	910-815-3122
Fax Number	:	910-642-8537

Provider Business Practice Location Address
First Line	:	101 CAROLINE AVE
Second Line	:
City	:	WELDON
State	:	NC
Zip	:	27890-1761
Country	:	US
Telephone Number	:	252-536-4817
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JOE CALCUTT
Credential	:
Telephone Number	:	910-815-3122

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	09/11/2019

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