Provider Demographics
NPI:1821306580
Name:CAREGIVERS OF LIBERTY II
Entity Type:Organization
Organization Name:CAREGIVERS OF LIBERTY II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:ISHMEAL
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-622-2348
Mailing Address - Street 1:125 E RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-3305
Mailing Address - Country:US
Mailing Address - Phone:336-622-2348
Mailing Address - Fax:
Practice Address - Street 1:125 E RALEIGH AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3305
Practice Address - Country:US
Practice Address - Phone:336-622-2348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAREGIVERS OF LIBERTY I
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-076-033310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804676Medicaid