MEDICARE: LIBERTY LIVING, LLC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1487971057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY LIVING, LLC

Provider Business Mailing Address
First Line	:	142 DOWNEY LAKE RD
Second Line	:
City	:	DALLAS
State	:	NC
Zip	:	28034-9395
Country	:	US
Telephone Number	:	704-622-3795
Fax Number	:	704-922-7337

Provider Business Practice Location Address
First Line	:	70 WOODFIN PL
Second Line	:	STE 307
City	:	ASHEVILLE
State	:	NC
Zip	:	28801-2466
Country	:	US
Telephone Number	:	704-922-9130
Fax Number	:	704-922-7337

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. CHARLOTTE DIANE RASH
Credential	:	LPN
Telephone Number	:	704-622-3795

Provider Enumeration Date	:	04/22/2010
Last Update Date	:	04/22/2010

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