=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629373634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2011
-----------------------------------------------------
Last Update Date | 01/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6245 MULAN ST
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-0793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-280-3001
-----------------------------------------------------
Fax | 951-280-3002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3045 S ARCHIBALD AVE STE H SUITE 299
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91761-9001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-280-3001
-----------------------------------------------------
Fax | 951-280-3002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ROBERT MCCOLLUM JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-280-3001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 201016110114
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------