1528623329 NPI number — LIBERTY MEDICAL DEVELOPMENT, LLC

Table of content: DEISY LUCIA FLORES DURAN (NPI 1891589982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528623329 NPI number — LIBERTY MEDICAL DEVELOPMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY MEDICAL DEVELOPMENT, LLC
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:
1528623329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST THOMAS
Provider Business Mailing Address State Name:
VI
Provider Business Mailing Address Postal Code:
00801-4567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
340-779-2663
Provider Business Mailing Address Fax Number:
340-779-2443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4006 ESTATE DIAMOND STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHRISTIANSTED
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00820-4534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
340-718-2664
Provider Business Practice Location Address Fax Number:
340-779-2443
Provider Enumeration Date:
05/07/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BACOT
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
340-779-2663

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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