Provider Demographics
NPI:1669449542
Name:TRC OF LOUISBURG, INC.
Entity Type:Organization
Organization Name:TRC OF LOUISBURG, INC.
Other - Org Name:LOUISBURG MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-679-8852
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-0589
Mailing Address - Country:US
Mailing Address - Phone:919-496-6084
Mailing Address - Fax:919-496-5458
Practice Address - Street 1:114 SMOKETREE WAY
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2117
Practice Address - Country:US
Practice Address - Phone:919-496-6084
Practice Address - Fax:919-496-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-035-003311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801294Medicaid