1275996431 NPI number — LIBERTY POINT RESIDENTAL TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275996431 NPI number — LIBERTY POINT RESIDENTAL TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY POINT RESIDENTAL TREATMENT CENTER
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:
6
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:
1275996431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 MONTGOMERGY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAUNTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-213-0450
Provider Business Mailing Address Fax Number:
540-213-0480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 MONTGOMERY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAUNTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24401-3968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-213-0450
Provider Business Practice Location Address Fax Number:
540-213-0480
Provider Enumeration Date:
04/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MOULTON
Authorized Official First Name:
PATTI
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PSYCHIATRY
Authorized Official Telephone Number:
540-213-0450

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  0101040563 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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