Healthcare Provider Details

I. General information

NPI: 1851353486
Provider Name (Legal Business Name): LIBERTY HEALTHCARE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 E PINE LOG RD SUITE B
AIKEN SC
29803-9695
US

IV. Provider business mailing address

2334 S 41ST ST
WILMINGTON NC
28403-5502
US

V. Phone/Fax

Practice location:
  • Phone: 803-643-0001
  • Fax: 803-649-0490
Mailing address:
  • Phone: 910-815-3122
  • Fax: 910-815-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHHA-196
License Number StateSC

VIII. Authorized Official

Name: MR. ANTHONY J. ZIZZAMIA JR.
Title or Position: MANAGER
Credential:
Phone: 910-815-3122