Healthcare Provider Details

I. General information

NPI: 1902855729
Provider Name (Legal Business Name): LIBERTY HEALTH SUPPLY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 JAY ST SUITE E
ROCHESTER NY
14611-1153
US

IV. Provider business mailing address

1099 JAY ST SUITE E
ROCHESTER NY
14611-1153
US

V. Phone/Fax

Practice location:
  • Phone: 585-235-1370
  • Fax: 585-235-1385
Mailing address:
  • Phone: 585-235-1370
  • Fax: 585-235-1385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA KOZAK
Title or Position: OFFICE MANAGER
Credential:
Phone: 585-235-1370