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General NPI Number Information
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NPI Number | 1871671396
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Entity Type | Organization
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Legal Business Name | LIQUID BLUE OXYGEN, INC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 482 DONALDSON RD
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City | KENNERDELL
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State | PA
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Zip | 16374-1504
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Country | US
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Telephone | 814-385-1321
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Fax | 814-385-1319
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Provider Business Mailing Address
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Address Line | 482 DONALDSON RD
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City | KENNERDELL
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State | PA
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Zip | 16374-1504
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Country | US
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Telephone | 814-385-1321
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Fax | 814-385-1319
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Authorized Official
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Title or Position | PRESIDENT
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Name | DANIELLE D FYOCK II
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Credential |
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Telephone | 814-385-1321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number | 8000001243
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License Number State | PA
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