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General NPI Number Information
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NPI Number | 1508338708
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Entity Type | Organization
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Legal Business Name | LIBERTY PROVIDER LLC
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Dates
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Enumeration Date | 12/28/2018
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Last Update Date | 12/28/2018
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Provider Practice Location Address
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Address Line | 7110 W CENTRAL AVE STE A
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City | TOLEDO
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State | OH
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Zip | 43617-3118
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Country | US
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Telephone | 419-517-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 7110 W CENTRAL AVE STE A
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City | TOLEDO
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State | OH
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Zip | 43617-3118
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Country | US
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Telephone | 419-517-7000
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | WILLIAM TIMOTHY BRUCK
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Credential |
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Telephone | 734-344-7331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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