1427088343 NPI number — LIBERTY HEALTH SUPPLIES, LLC

Table of content: (NPI 1427088343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427088343 NPI number — LIBERTY HEALTH SUPPLIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY HEALTH SUPPLIES, 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:
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:
1427088343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1151 STRATFORD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06615-6312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-377-1144
Provider Business Mailing Address Fax Number:
866-381-6072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1151 STRATFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06615-6312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-377-1144
Provider Business Practice Location Address Fax Number:
866-381-6072
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLETCHER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-377-1144

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0285908-000 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2V6016 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 12DME0968CT01 . This is a "ANTHEM BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 171441 . This is a "WELLCARE OF CONN." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004235728 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82-02085 . This is a "EVERCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A881654 . This is a "OXFORD HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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