# TAR RIVER LTC GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** River Trace Nursing and Rehabilitation Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1750317897
- **Authorized official:** MS. KAREN G MCDANIEL (PRESIDENT)
- **Authorized official phone:** (252) 523-9094

## Contact information

- **Practice address:** 250 LOVERS LN, WASHINGTON, NC 27889-3436
- **Practice address phone:** (252) 975-1636
- **Practice address fax:** (252) 975-5960
- **Mailing address:** PO BOX 398, WASHINGTON, NC 27889-0398
- **Mailing address phone:** (252) 975-1636
- **Mailing address fax:** (252) 975-5960

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | NH0345 | NC | Yes |

## Other

- **Enumeration date:** 06/23/2006
- **Last updated:** 07/14/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0089L | BC/BS OF NC | NC |
| 05 | — | 3415215 | — | NC |
| 05 | — | 3425215 | — | NC |
| 01 | — | 7801167 | MEDICAID ADULT CARE \# | NC |