NPIMap

Organization Active NPI

Eagle Peak LTC Group, LLC

  • Skilled Nursing Facility
  • Henderson, NC
National Provider Identifier
1972547321
Registry record updated Jul 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
NH0353 Issued in NC
Legal business name
EAGLE PEAK LTC GROUP, LLC
Practice address
1245 Park Ave
Henderson, NC 27536-4025
Phone
(252) 492-7021
Fax
(252) 492-2985
NPI assigned
Jun 16, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Karen G McDaniel
Title
President
Phone
(252) 523-9094

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NH0353 NC Primary

Addresses

Primary practice location

1245 Park Ave
Henderson, NC 27536-4025

Mailing address

PO Box 1148
Henderson, NC 27536-1148
Phone (252) 492-7021

Other identifiers 4

IdentifierTypeStateIssuer
3425321MedicaidNC
0088DOtherNCBC/BS OF NC
3415321MedicaidNC
7806629MedicaidNC

Other names 1

  • Kerr Lake Nursing and Rehabilitation Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Ability Network

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110502000304 NC Part A Provider - Skilled Nursing Facility 5698956613 Practice locations: Henderson, NC

Skilled nursing facility certification: CCN 345321

Legal name
EAGLE PEAK LTC GROUP, LLC
Doing business as
KERR LAKE NURSING AND REHABILITATION CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jul 13, 1990
Last certification
Nov 6, 2024
Beds
115 (92 certified)
Ownership / control type
Corporation
Multi-facility organization
Principle LTC
Organization structure
LLCProprietary
Incorporated
Aug 20, 2010 in NC
Enrollment address
1245 Park Avenue
Henderson, NC 27536-4025
Nursing home name
KERR LAKE NURSING AND REHABILITATION CENTER
Affiliated entity
PRINCIPLE LONG TERM CARE

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Kerr Lake Nursing and Rehabilitation CenterCCN 345321
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
4 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Jul 13, 1990
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
9269.4 residents per day on average
Chain
Principle Long Term Care40 facilities in the chain
Penalties (3 years)
1Fines totaling $19,620

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Valarmathi Sundar Individual Managing Control - Governing Body Jan 1, 2025
Adp of the SNF Jun 11, 2025
Raymond Gregg Hill Individual 5% Or Greater Indirect Ownership Interest Jan 1, 2011 18%
Nancy W Hughes Individual Operational/Managerial ControlAdministrator Jan 1, 2011
Adp of the SNF Apr 14, 2025
Robert O'Neil Hill Individual 5% Or Greater Indirect Ownership Interest Jan 1, 2011 21%
Stephen Britt Hill Individual 5% Or Greater Indirect Ownership InterestOwner Jan 1, 2011 20%
Gale R Boice Individual Corporate OfficerCfo Mar 5, 2018
Dianne Johnson Individual Corporate Director Jan 1, 2011
Principle Long Term Care, Inc. Organization, Kinston, NC Corporation, For-profit, Chain home office 5% Or Greater Direct Ownership Interest Jan 1, 2011 50%
Operational/Managerial Control Jan 1, 2011
Principle It Services, Inc. Organization, Kinston, NC For-profit 5% Or Greater Direct Ownership Interest Jan 1, 2011 50%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 43

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 43

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1626393600000",
    "number": "1972547321",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1148",
            "city": "HENDERSON",
            "state": "NC",
            "postal_code": "275361148",
            "telephone_number": "252-492-7021",
            "fax_number": "252-492-2985"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1245 PARK AVE",
            "city": "HENDERSON",
            "state": "NC",
            "postal_code": "275364025",
            "telephone_number": "252-492-7021",
            "fax_number": "252-492-2985"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE PEAK LTC GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-16",
        "last_updated": "2021-07-16",
        "certification_date": "2021-07-16",
        "status": "A",
        "authorized_official_last_name": "MCDANIEL",
        "authorized_official_first_name": "KAREN",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "252-523-9094",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NC",
            "license": "NH0353",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3425321",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS OF NC",
            "identifier": "0088D",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3415321",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7806629",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "affiliationName": "Ability Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 N 6th St Ste 900A",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Kerr Lake Nursing and Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Kerr Lake Nursing and Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Henderson, NC

Sources for this page

Verify at the official NPI Registry.