Provider Demographics
NPI:1881993079
Name:LIBERTY HEALTHCARE GROUP, LLC
Entity type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
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 1:901 BETHESDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3015
Practice Address - Country:US
Practice Address - Phone:336-768-2211
Practice Address - Fax:336-774-6545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0439314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3415284Medicaid
NC345284Medicare Oscar/Certification