Provider Demographics
NPI:1548206907
Name:EVEREST LONG TERM CARE, LLC
Entity Type:Organization
Organization Name:EVEREST LONG TERM CARE, LLC
Other - Org Name:LAKE PARK NURSING & 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 2518
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-2518
Mailing Address - Country:US
Mailing Address - Phone:704-882-3420
Mailing Address - Fax:704-882-5197
Practice Address - Street 1:3315 FAITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9300
Practice Address - Country:US
Practice Address - Phone:704-882-3420
Practice Address - Fax:704-882-5197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0592314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340613BMedicaid
NC00867OtherBC/BS OF NC
NC3405502Medicaid
NC3415502Medicaid
NC3415502Medicaid