Provider Demographics
NPI:1962447565
Name:REDWOOD LTC GROUP, LLC
Entity Type:Organization
Organization Name:REDWOOD LTC GROUP, LLC
Other - Org Name:PREMIER NURSING AND 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 1:225 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6351
Mailing Address - Country:US
Mailing Address - Phone:910-353-7222
Mailing Address - Fax:910-353-8010
Practice Address - Street 1:225 WHITE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6351
Practice Address - Country:US
Practice Address - Phone:910-353-7222
Practice Address - Fax:910-353-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0229314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405217Medicaid
NC00959OtherBC/BS OF NC
NC00959OtherSTATE HEALTH PLAN #
NC7802298Medicaid
NC3415217Medicaid
NC00959OtherSTATE HEALTH PLAN #
NC3475217Medicaid
NC3415217Medicaid