Provider Demographics
NPI:1356386445
Name:TAR RIVER LTC GROUP, LLC
Entity type:Organization
Organization Name:TAR RIVER LTC GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NORWOOD
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:UZZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-523-9094
Mailing Address - Street 1:430 W HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-8943
Mailing Address - Country:US
Mailing Address - Phone:252-441-3116
Mailing Address - Fax:252-441-0247
Practice Address - Street 1:430 W HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-8943
Practice Address - Country:US
Practice Address - Phone:252-441-3116
Practice Address - Fax:252-441-0247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0372314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406309Medicaid
NC3415226Medicaid
NC00965OtherBLUE CROSS/BLUE SHIELD
NC7802299Medicaid
NC3425226Medicaid
NC345226Medicare ID - Type UnspecifiedMEDICARE PROVIDER #