Healthcare Provider Details

I. General information

NPI: 1154747871
Provider Name (Legal Business Name): LIBERAL URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132 N KANSAS AVE STE A
LIBERAL KS
67901-2099
US

IV. Provider business mailing address

2132 N KANSAS AVE STE A
LIBERAL KS
67901-2099
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-3700
  • Fax: 620-624-3702
Mailing address:
  • Phone: 620-624-3700
  • Fax: 620-624-3702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0428884
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number0428884
License Number StateKS

VIII. Authorized Official

Name: MARIANA E LUCERO
Title or Position: OWNER
Credential: M.D.
Phone: 620-624-3700