1891852323 NPI number — LIBERTY MEDICAL SPECIALTIES, INC

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 1891852323 NPI number — LIBERTY MEDICAL SPECIALTIES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY MEDICAL SPECIALTIES, INC
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:
1891852323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 339
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28472-0339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-642-2250
Provider Business Mailing Address Fax Number:
910-642-0109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 OCEAN HWY WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-755-0023
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
910-642-2250

Provider Taxonomy Codes

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

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

  • Identifier: 7704895 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0476T . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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