MEDICARE: LIBERTY LABORATORY 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1689056855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY LABORATORY LLC

Provider Business Mailing Address
First Line	:	10760 WARNER AVE STE 201
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-3857
Country	:	US
Telephone Number	:	714-593-5356
Fax Number	:	714-593-5366

Provider Business Practice Location Address
First Line	:	10760 WARNER AVE STE 201
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-3857
Country	:	US
Telephone Number	:	714-593-5356
Fax Number	:	714-593-5366

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. ROCHELLE ALI
Credential	:	MA
Telephone Number	:	714-593-5356

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	06/24/2015

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