MEDICARE: LIBERTY TOWNSHIP TRUSTEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	0187	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306022777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY TOWNSHIP TRUSTEE

Provider Business Mailing Address
First Line	:	300 S MAIN ST
Second Line	:	PO BOX 729
City	:	NORTH LIBRTY
State	:	IN
Zip	:	46554-0729
Country	:	US
Telephone Number	:	574-656-4587
Fax Number	:	574-656-4580

Provider Business Practice Location Address
First Line	:	108 SOUTH STREET
Second Line	:
City	:	NORTH LIBERTY
State	:	IN
Zip	:	46554
Country	:	US
Telephone Number	:	574-656-4587
Fax Number	:

Authorized Official
Title or Position	:	TRUSTEE ASSESSOR
Name	:	MRS. SUE A DITTMAR
Credential	:
Telephone Number	:	574-656-4587

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	06/23/2016

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