Provider Demographics
NPI:1376178053
Name:LIBERTY LODGE, INC.
Entity Type:Organization
Organization Name:LIBERTY LODGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-397-9098
Mailing Address - Street 1:PO BOX 3915
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78333-3915
Mailing Address - Country:US
Mailing Address - Phone:361-664-7555
Mailing Address - Fax:
Practice Address - Street 1:160 FM 2507
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-7763
Practice Address - Country:US
Practice Address - Phone:361-664-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder