Provider Demographics
NPI:1083659692
Name:TAR RIVER LTC GROUP, LLC
Entity Type:Organization
Organization Name:TAR RIVER LTC GROUP, LLC
Other - Org Name:CHOWAN RIVER NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-523-9094
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-0566
Mailing Address - Country:US
Mailing Address - Phone:252-482-7481
Mailing Address - Fax:252-482-7674
Practice Address - Street 1:1341 PARADISE RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-8503
Practice Address - Country:US
Practice Address - Phone:252-482-7481
Practice Address - Fax:252-482-7674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0369261QR0400X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802461Medicaid
NC00809OtherBC/BS OF NC
NC3425164Medicaid
NC7802461Medicaid
NC00809OtherBC/BS OF NC
NC7802461Medicaid