Provider Demographics
NPI:1821024274
Name:EAGLE PEAK LTC GROUP, LLC
Entity Type:Organization
Organization Name:EAGLE PEAK LTC GROUP, LLC
Other - Org Name:ENFIELD OAKS NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:GALE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-523-9094
Mailing Address - Street 1:1435 HIGHWAY 258N
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-7208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 CARY ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:NC
Practice Address - Zip Code:27823-1204
Practice Address - Country:US
Practice Address - Phone:252-445-2111
Practice Address - Fax:252-445-5646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0037314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3425101Medicaid
NC3415101Medicaid
NC91-0085DOtherSTATE HEALTH PLAN
NC0085DOtherBC/BS OF NC
NC3416559Medicaid
NC3416559Medicaid