Provider Demographics
NPI:1326041468
Name:LIBERTY HEALTHCARE GROUP LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP LLC
Other - Org Name:LIBERTY HOME CARE VII, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:ZIZZAMIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:RN
Authorized Official - Phone:910-332-1941
Mailing Address - Street 1:1719 QUARTER RD
Mailing Address - Street 2:
Mailing Address - City:SWANQUARTER
Mailing Address - State:NC
Mailing Address - Zip Code:27885-9616
Mailing Address - Country:US
Mailing Address - Phone:252-926-3715
Mailing Address - Fax:252-926-3702
Practice Address - Street 1:1719 QUARTER RD
Practice Address - Street 2:
Practice Address - City:SWANQUARTER
Practice Address - State:NC
Practice Address - Zip Code:27885-9616
Practice Address - Country:US
Practice Address - Phone:252-926-3715
Practice Address - Fax:252-926-3702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC0379251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0078GOtherBCBS
NC3407096Medicaid
NCHC0379OtherAGENCY LICENSE
NC347096Medicare ID - Type Unspecified
NC3408599Medicaid
NC=========OtherTAX IDENTIFICATION
NC347096Medicare ID - Type Unspecified