Granite Falls LTC, LLC
Organization Active NPI Skilled Nursing Facility · Madison, NC
NPI 1255367447 · NPPES record last updated Jul 14, 2021
Key facts
- NPI
- 1255367447
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- License
- NH0092 (NC)
- Legal business name
- GRANITE FALLS LTC, LLC
- Practice address
- 1721 Bald Hill Loop
Madison, NC 27025-7624 - Phone
- (336) 548-9658
- Fax
- (336) 548-1299
- NPI assigned
- Jun 23, 2006
- Organization subpart
- No
Authorized official
- Name
- Ms. Karen G McDaniel
- Title
- President
- Phone
- (252) 523-9094
Owners & managing parties with NPI records 1
-
James Walter Goforth, M.D
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 5
Facilities with the same owner 43
Practitioners 1
-
James Walter Goforth, M.D
Affiliated clinicians 1
-
James Walter Goforth, M.D
Medicare Care Compare: Nursing home
- Listed as
- Jacob's Creek Nursing and Rehabilitation Center
- Overall star rating
- ★★★★★ 5 of 5
- Health inspections
- ★★★★☆ 4 of 5
- Staffing
- ★★★☆☆ 3 of 5
- Quality measures
- ★★★★★ 5 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified
- May 8, 1968
- Medicare certification status
- Active
- Certified beds
- 170 · 152.2 residents per day on average
- Chain
- Principle Long Term Care
- Penalties (3 years)
- 3 · fines totaling $16,801
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 34D0931113 | Granite Falls LTC, LLC | Certificate of waiver | Jul 22, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NC
Skilled nursing facility certification: CCN 345050
- Legal name
- GRANITE FALLS LTC, LLC
- Doing business as
- JACOBS CREEK NURSING AND REHABILITATION CENTER
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- May 8, 1968
- Last certification
- Sep 18, 2024
- Beds
- 170
- Ownership / control type
- Limited Liability Corporation
- Organization structure
- LLC · Proprietary
- Incorporated
- Aug 20, 2010 in NC
- Enrollment address
- 1721 Bald Hill Loop
Madison, NC 27025-7624 - Nursing home name
- JACOB'S CREEK NURSING AND REHABILITATION CENTER
- Affiliated entity
- PRINCIPLE LONG TERM CARE
All disclosed owners & managing parties 9
| Name | Role | Since | Share |
|---|---|---|---|
| Raymond Gregg Hill |
5% Or Greater Indirect Ownership Interest | Jan 1, 2011 | 18% |
| Robert O'Neil Hill |
5% Or Greater Indirect Ownership Interest | Jan 1, 2011 | 20% |
| Stephen Britt Hill |
5% Or Greater Indirect Ownership Interest | Jan 1, 2011 | 20% |
| Gale R Boice |
Corporate Officer |
Mar 5, 2018 | |
| Dianne Johnson |
Corporate Officer |
Jan 1, 2011 | |
| Principle Long Term Care, Inc. |
5% Or Greater Direct Ownership Interest | Jan 1, 2011 | 50% |
| Operational/Managerial Control | Jan 1, 2011 | 50% | |
| Adp of the SNF | Apr 14, 2025 | ||
| Kathleen S Wilson |
Operational/Managerial Control | Jan 1, 2025 | |
| Adp of the SNF | May 12, 2025 | ||
| Principle It Services, Inc. |
5% Or Greater Direct Ownership Interest | Jan 1, 2011 | 50% |
| James Walter Goforth |
Managing Control - Governing Body | Jan 1, 2025 | |
| Adp of the SNF | May 12, 2025 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110413000355 | NC | Part a Provider - Skilled Nursing Facility | 5799966727 | Practice locations: Madison, NC |
National Provider Directory
- Tax ID family
- Ability Network
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | NH0092 | NC | Yes |
Addresses
Primary practice location
1721 Bald Hill Loop
Madison, NC 27025-7624
Mailing address
1721 Bald Hill Loop
Madison, NC 27025-7624
Phone (336) 548-9658
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3425050 | Medicaid | NC | |
| 561370182 | Other | NC | UNITED HEALTHCARE # |
| 24380 | Other | NC | PARTNERS INSURANCE |
| 0091B | Other | NC | BC/BS OF NC |
| 3415050 | Medicaid | NC |
Other names
- Jacob's Creek Nursing and Rehabilitation Center
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Ability Network |
Other providers in Madison, NC
- Cheryl Rumley Garrity
- Gentle Care Transportation
- James Giangaspro
- Kristin Danielle Gillikin
- Katherine N Graham
- Mark Wayne Gregson
- GSTS Designs, LLC
- Latoya Jeanette Hairston
- Christy Ann Hawks
- Katherine Vaughan Hemberg
All providers in Madison, NC · Skilled Nursing Facility in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 14, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.