Healthcare Provider Details

I. General information

NPI: 1407234487
Provider Name (Legal Business Name): LIBERTY RESIDENTIAL CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2878 RAVENSWOOD CT
COLUMBUS OH
43232-3830
US

IV. Provider business mailing address

2878 RAVENSWOOD CT
COLUMBUS OH
43232-3830
US

V. Phone/Fax

Practice location:
  • Phone: 614-843-1696
  • Fax:
Mailing address:
  • Phone: 614-843-1696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL L PAYNE
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 614-843-1696