Provider Demographics
NPI:1265468441
Name:BIRCH LTC GROUP, LLC
Entity Type:Organization
Organization Name:BIRCH LTC GROUP, LLC
Other - Org Name:LAGRANGE GARDENS ASSISTED LIVING
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 428
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-0428
Mailing Address - Country:US
Mailing Address - Phone:252-566-4112
Mailing Address - Fax:252-566-2267
Practice Address - Street 1:167 FUSSELL RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551-7745
Practice Address - Country:US
Practice Address - Phone:252-566-4112
Practice Address - Fax:252-566-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL096001311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806624Medicaid
NC7801106Medicaid
NCW1265264509OtherBC/BS OF NC