1033426234 NPI number — LIBERTY MEDICAL SUPPLY INC

Table of content: (NPI 1033426234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033426234 NPI number — LIBERTY MEDICAL SUPPLY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY MEDICAL SUPPLY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033426234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8881 LIBERTY LN
Provider Second Line Business Mailing Address:
ATTN:COMPLIANCE
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-3477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-398-5800
Provider Business Mailing Address Fax Number:
772-398-2192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10400 S US HIGHWAY 1
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-907-0835
Provider Business Practice Location Address Fax Number:
877-592-8466
Provider Enumeration Date:
09/09/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT/DIRECTOR
Authorized Official Telephone Number:
772-398-5860

Provider Taxonomy Codes

  • Taxonomy code: 3336M0002X , with the licence number:  PH16634 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)