Provider Demographics
NPI:1043263981
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:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-332-1793
Mailing Address - Street 1:2334 SOUTH 41ST STREET
Mailing Address - Street 2:LIBERTY HEALTHCARE MANAGEMENT INC
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-332-1777
Mailing Address - Fax:910-815-3114
Practice Address - Street 1:180 SOUTHWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28329
Practice Address - Country:US
Practice Address - Phone:910-592-8165
Practice Address - Fax:910-596-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0571314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00991OtherBCBS
NC341609ZMedicaid
NC3415472Medicaid
NC00991OtherBCBS
NC4736300002Medicare NSC