Provider Demographics
NPI:1154098077
Name:LIBERTY FAMILY CARE LLC
Entity Type:Organization
Organization Name:LIBERTY FAMILY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOLAJI
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUGBOJA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-301-6767
Mailing Address - Street 1:8515 LIBERTY RD STE B
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4832
Mailing Address - Country:US
Mailing Address - Phone:410-301-6767
Mailing Address - Fax:410-496-3121
Practice Address - Street 1:8515 LIBERTY RD STE B
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4832
Practice Address - Country:US
Practice Address - Phone:410-301-6767
Practice Address - Fax:410-496-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR210237OtherLICENSE