=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144375049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1133 N LIBERTY LN
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805-1544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-535-2943
-----------------------------------------------------
Fax | 714-956-7303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15331 NORMANDY LN
-----------------------------------------------------
City | LA MIRADA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90638-4745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-535-2943
-----------------------------------------------------
Fax | 714-956-7303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAGIE FRANI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-213-5009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------