Healthcare Provider Details

I. General information

NPI: 1225188923
Provider Name (Legal Business Name): LIBERTY CLUB SENIORS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10329 CROSS CREEK BLVD SUITE P
TAMPA FL
33647-2994
US

IV. Provider business mailing address

10329 CROSS CREEK BLVD SUITE P
TAMPA FL
33647-2994
US

V. Phone/Fax

Practice location:
  • Phone: 813-991-1960
  • Fax: 813-991-1961
Mailing address:
  • Phone: 813-991-1960
  • Fax: 813-991-1961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: ETHEL CATLIN
Title or Position: CHIEF ADMINISTRATOR
Credential: MSW-ACSW
Phone: 813-991-1960