Provider Demographics
NPI:1457709891
Name:LIBERTY HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP, LLC
Other - Org Name:SOUTHPORT NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:V
Authorized Official - Last Name:CALCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-815-3122
Mailing Address - Street 1:44 MCNEILL PLZ
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-8602
Mailing Address - Country:US
Mailing Address - Phone:910-642-0224
Mailing Address - Fax:910-642-8537
Practice Address - Street 1:924 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3038
Practice Address - Country:US
Practice Address - Phone:910-457-3800
Practice Address - Fax:910-454-4628
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY HEALTHCARE GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-26
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC345504Medicare Oscar/Certification