1730267105 NPI number — LIBERTY HEALTHCARE GROUP, LLC

Table of content: (NPI 1730267105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730267105 NPI number — LIBERTY HEALTHCARE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY HEALTHCARE GROUP, 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:
LIBERTY HOME CARE II, LLC
Provider Other Organization Name Type Code:
3
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:
1730267105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2334 S 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-5502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-815-3122
Provider Business Mailing Address Fax Number:
910-815-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 CARTHAGE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27331-0066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-774-9522
Provider Business Practice Location Address Fax Number:
919-774-8560
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZIZZAMIZ
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT/EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
910-815-3122

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  HOS3086 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3421537 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007CH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com