Provider Demographics
NPI:1225188923
Name:LIBERTY CLUB SENIORS INC
Entity Type:Organization
Organization Name:LIBERTY CLUB SENIORS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CATLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW-ACSW
Authorized Official - Phone:813-991-1960
Mailing Address - Street 1:10329 CROSS CREEK BLVD
Mailing Address - Street 2:SUITE P
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2994
Mailing Address - Country:US
Mailing Address - Phone:813-991-1960
Mailing Address - Fax:813-991-1961
Practice Address - Street 1:10329 CROSS CREEK BLVD
Practice Address - Street 2:SUITE P
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2994
Practice Address - Country:US
Practice Address - Phone:813-991-1960
Practice Address - Fax:813-991-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty