Provider Demographics
NPI:1962832899
Name:LIBERTY HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP, LLC
Other - Org Name:LIBERTY COMMONS NSG & REHAB CTR OF BALLANTYNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE FINANCIAL CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:PURIFOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-642-0224
Mailing Address - Street 1:2334 41ST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5502
Mailing Address - Country:US
Mailing Address - Phone:910-815-3122
Mailing Address - Fax:910-815-3111
Practice Address - Street 1:10011 PROVIDENCE RD W
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1561
Practice Address - Country:US
Practice Address - Phone:980-245-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-13
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC345563Medicare Oscar/Certification