Provider Demographics
NPI:1144716903
Name:LIBERTY HEALTHCARE GROUP LLC
Entity type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-815-3122
Mailing Address - Street 1:2334 SOUTH 41ST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5502
Mailing Address - Country:US
Mailing Address - Phone:910-815-3122
Mailing Address - Fax:910-815-3111
Practice Address - Street 1:212 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27938
Practice Address - Country:US
Practice Address - Phone:252-926-3715
Practice Address - Fax:252-926-3702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC347049OtherMEDICARE