1932257375 NPI number — LIBERTY III MANAGEMENT TR

Table of content: (NPI 1932257375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932257375 NPI number — LIBERTY III MANAGEMENT TR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY III MANAGEMENT TR
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:
1932257375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85080-6658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-509-2001
Provider Business Mailing Address Fax Number:
623-587-7533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21620 N 19TH AVE
Provider Second Line Business Practice Location Address:
A102
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85027-2716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-587-0012
Provider Business Practice Location Address Fax Number:
623-587-7533
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORNEJO
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
623-587-0012

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  07498747M , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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