Provider Demographics
NPI:1215190673
Name:LIBERTY MEDICAL, LLC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-2122
Mailing Address - Street 1:8881 S US HIGHWAY 1
Mailing Address - Street 2:ATTN: LICENSING
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3401
Mailing Address - Country:US
Mailing Address - Phone:772-398-2122
Mailing Address - Fax:844-363-4341
Practice Address - Street 1:1801 N ROBISON RD
Practice Address - Street 2:SUITE 13
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:800-898-0477
Practice Address - Fax:844-363-4341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY MEDICAL HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-07
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1001500332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363906401Medicaid
AR176981716Medicaid
TX1001500OtherDEVICE DISTRIBUTOR LICENSE
AR176981716Medicaid