MEDICARE: LIBERTY I, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10D1011161	OTHER	FL	CLIA WAIVER ID
2	299992257	OTHER	FL	AHCA STATE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	299991756	OTHER	FL	AHCA STATE LICENSE
5	299992984	OTHER	FL	AHCA STATE LICENSE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588616015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY I, LLC

Provider Business Mailing Address
First Line	:	4655 SALISBURY RD STE 110
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-0957
Country	:	US
Telephone Number	:	904-733-1003
Fax Number	:	904-448-8855

Provider Business Practice Location Address
First Line	:	5810 W CYPRESS ST STE 5810-A
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-1780
Country	:	US
Telephone Number	:	813-636-5017
Fax Number	:	813-282-1166

Authorized Official
Title or Position	:	SECRETARY & CAO
Name	:	MR. ROBERT G YOUNG
Credential	:
Telephone Number	:	904-733-1003

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	12/27/2023

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Directions to “LIBERTY I, LLC ” Practice Location

Language	Start Address	Practice Location

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