Provider Demographics
NPI:1548278948
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:PRESIDENT/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZIZZAMIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:RN
Authorized Official - Phone:910-815-3122
Mailing Address - Street 1:2334 S 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 1:1220 21ST AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7401
Practice Address - Country:US
Practice Address - Phone:843-839-2273
Practice Address - Fax:843-839-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHPC093251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCHSP072Medicaid
NC007AOtherBLUE CROSS BLUE SHIELD
SCHSP072Medicaid