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General NPI Number Information
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NPI Number | 1376178053
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Entity Type | Organization
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Legal Business Name | LIBERTY LODGE, INC.
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Dates
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Enumeration Date | 03/03/2020
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Last Update Date | 01/24/2023
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Provider Practice Location Address
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Address Line | 160 FM 2507
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City | ALICE
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State | TX
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Zip | 78332-7763
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Country | US
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Telephone | 361-664-7555
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3915
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City | ALICE
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State | TX
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Zip | 78333-3915
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Country | US
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Telephone | 361-664-7555
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | RHONDA PATRICK
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Credential |
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Telephone | 713-397-9098
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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