1609864990 NPI number — LIBERTY MEDICAL, LLC

Table of content: (NPI 1609864990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609864990 NPI number — LIBERTY MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY MEDICAL, 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:
1609864990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8881 S US HIGHWAY 1
Provider Second Line Business Mailing Address:
ATTN: LICENSING DEPARTMENT
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-3401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-398-2122
Provider Business Mailing Address Fax Number:
844-363-4341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
89 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01757-3141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-202-2420
Provider Business Practice Location Address Fax Number:
844-363-4341
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-398-2122

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30703422 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110020874E , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1557308-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1024762540001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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