Provider Demographics
NPI:1083220750
Name:LIBERTY RESIDENTIAL LLC
Entity Type:Organization
Organization Name:LIBERTY RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANAIT
Authorized Official - Middle Name:
Authorized Official - Last Name:REDAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-789-1839
Mailing Address - Street 1:4811 E COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-1205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4811 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-1205
Practice Address - Country:US
Practice Address - Phone:720-789-1839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities