MEDICARE: LIBERTY HEALTHCARE GROUP, 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

General Provider Information

NPI Number	:	1649464694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY HEALTHCARE GROUP, LLC

Provider Business Mailing Address
First Line	:	2334 S 41ST ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-5502
Country	:	US
Telephone Number	:	910-815-3122
Fax Number	:	910-815-3111

Provider Business Practice Location Address
First Line	:	500 PINEY FOREST RD
Second Line	:	SUITE G
City	:	DANVILLE
State	:	VA
Zip	:	24540-3315
Country	:	US
Telephone Number	:	434-799-2308
Fax Number	:	434-799-2356

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ANTHONY JOSEPH ZIZZAMIA JR.
Credential	:	RN
Telephone Number	:	910-815-3122

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	10/28/2011

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