Provider Demographics
NPI:1710244827
Name:LIBERTY HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP, LLC
Other - Org Name:LIBERTY COMMONS OF KERNERSVILLE, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-815-3122
Mailing Address - Street 1:44 MCNEILL PLZ
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-8602
Mailing Address - Country:US
Mailing Address - Phone:910-642-0224
Mailing Address - Fax:910-642-8537
Practice Address - Street 1:485 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9903
Practice Address - Country:US
Practice Address - Phone:336-767-2750
Practice Address - Fax:336-767-3862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC314000000X
NCNH0439335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405039Medicaid
NC345039Medicare Oscar/Certification