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General NPI Number Information
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NPI Number | 1104295583
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Entity Type | Organization
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Legal Business Name | LIBERTY HOUSE LLC
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Dates
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Enumeration Date | 09/16/2015
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 9314 FOREST HILL BLVD 313
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City | WELLINGTON
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State | FL
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Zip | 33411-6577
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Country | US
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Telephone | 561-460-4137
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Fax |
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Provider Business Mailing Address
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Address Line | 9314 FOREST HILL BLVD 313
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City | WELLINGTON
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State | FL
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Zip | 33411-6577
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | HENRY PAL REGAN
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Credential |
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Telephone | 561-460-4137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 10D2099701
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License Number State | FL
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