Healthcare Provider Details

I. General information

NPI: 1528623329
Provider Name (Legal Business Name): LIBERTY MEDICAL DEVELOPMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/24/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 ESTATE DIAMOND STE 203
CHRISTIANSTED VI
00820-4534
US

IV. Provider business mailing address

PO BOX 11567
ST THOMAS VI
00801-4567
US

V. Phone/Fax

Practice location:
  • Phone: 340-718-2664
  • Fax: 340-779-2443
Mailing address:
  • Phone: 340-779-2663
  • Fax: 340-779-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN BACOT
Title or Position: CEO
Credential: MD
Phone: 340-779-2663