Healthcare Provider Details

I. General information

NPI: 1154098077
Provider Name (Legal Business Name): LIBERTY FAMILY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 12/21/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8515 LIBERTY RD STE B
RANDALLSTOWN MD
21133-4832
US

IV. Provider business mailing address

8515 LIBERTY RD STE B
RANDALLSTOWN MD
21133-4832
US

V. Phone/Fax

Practice location:
  • Phone: 410-301-6767
  • Fax: 410-496-3121
Mailing address:
  • Phone: 410-301-6767
  • Fax: 410-496-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BOLAJI OLUGBOJA
Title or Position: OWNER
Credential: CRNP
Phone: 410-301-6767