Provider Demographics
NPI:1366585796
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:
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 1:2334 S 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:910-642-8537
Practice Address - Street 1:101 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:WELDON
Practice Address - State:NC
Practice Address - Zip Code:27890-1761
Practice Address - Country:US
Practice Address - Phone:252-536-4817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0469310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801656Medicaid