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General NPI Number Information
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NPI Number | 1568949758
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Entity Type | Organization
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Legal Business Name | LIBERTY MOBILE LABS INC
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Dates
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Enumeration Date | 07/20/2018
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Last Update Date | 11/23/2019
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Provider Practice Location Address
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Address Line | 541 SPRUCE RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-2504
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Country | US
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Telephone | 630-880-9454
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Fax | 630-596-1404
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Provider Business Mailing Address
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Address Line | 541 SPRUCE RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-2504
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Country | US
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Telephone | 630-880-9517
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Fax | 630-596-1404
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Authorized Official
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Title or Position | OWNER
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Name | MR. DONALD JOSEPH HANSEN
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Credential | AMCA-PCT 4709
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Telephone | 630-880-9517
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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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 | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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