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General NPI Number Information
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NPI Number | 1871590703
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Entity Type | Organization
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Legal Business Name | LIBERTY MEDICAL RURAL HEALTH CLINIC
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Dates
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Enumeration Date | 07/07/2005
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 720 TRAVIS ST
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City | LIBERTY
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State | TX
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Zip | 77575-4828
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Country | US
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Telephone | 936-336-6439
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Fax | 936-336-6517
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Provider Business Mailing Address
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Address Line | 720 TRAVIS ST
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City | LIBERTY
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State | TX
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Zip | 77575-4828
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Country | US
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Telephone | 936-336-6439
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Fax | 936-336-6517
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | FALLON BROOKE KAY
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Credential |
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Telephone | 936-336-6439
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 453892
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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