Healthcare Provider Details

I. General information

NPI: 1629167663
Provider Name (Legal Business Name): LIBERTY REHABILITATION PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 05/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 YMCA DR SUITE 5
MADISONVILLE KY
42431-9000
US

IV. Provider business mailing address

100 YMCA DR SUITE 5
MADISONVILLE KY
42431-9000
US

V. Phone/Fax

Practice location:
  • Phone: 270-824-9227
  • Fax: 270-824-9206
Mailing address:
  • Phone: 270-824-9227
  • Fax: 270-824-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number001533
License Number StateKY

VIII. Authorized Official

Name: FORREST L. WAIDE
Title or Position: PRESIDENT
Credential: P. T.
Phone: 270-824-9227