=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508040676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY HEALTHCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2007
-----------------------------------------------------
Last Update Date | 02/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 S BROAD ST STE 305
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43130-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-901-3026
-----------------------------------------------------
Fax | 740-901-3028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 S BROAD ST STE 305
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43130-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-503-5933
-----------------------------------------------------
Fax | 740-901-3028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | VIENGKEO BOUNEMANY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-747-3356
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1588347
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------