Basic Information
| Provider Information | |||||||||
| NPI: | 1770529141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAR RIVER LTC GROUP, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OPEN FIELDS ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | TARBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278861828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528238546 | ||||||||
| FaxNumber: | 2528233878 | ||||||||
| Practice Location | |||||||||
| Address1: | 3210 WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | TARBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278861828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528238546 | ||||||||
| FaxNumber: | 2528233878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCDANIEL | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2525239094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | HAL033001 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7806623 | 05 | NC | MEDICAID |