Healthcare Provider Details

I. General information

NPI: 1700162203
Provider Name (Legal Business Name): LIBERTY DOCTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8761 DORCHESTER RD STE 230
CHARLESTON SC
29420-7322
US

IV. Provider business mailing address

8761 DORCHESTER RD STE 230
CHARLESTON SC
29420-7322
US

V. Phone/Fax

Practice location:
  • Phone: 843-471-2273
  • Fax: 843-377-8180
Mailing address:
  • Phone: 843-412-1590
  • Fax: 843-225-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number30704
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number3438
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number1804
License Number StateSC

VIII. Authorized Official

Name: MRS. LISSA C LARA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 843-412-1590