Healthcare Provider Details

I. General information

NPI: 1629156872
Provider Name (Legal Business Name): LIBERTY HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 OCEAN HWY. WEST
SUPPLY NC
28462-4036
US

IV. Provider business mailing address

2334 S 41ST ST
WILMINGTON NC
28403-5502
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-8133
  • Fax: 910-754-2096
Mailing address:
  • Phone: 910-815-3122
  • Fax: 910-815-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License NumberHOS2006
License Number StateNC

VIII. Authorized Official

Name: MR. ANTHONY J. ZIZZAMIA JR.
Title or Position: PRESIDENT/EXECUTIVE DIRECTOR
Credential: RN
Phone: 910-815-3122