Provider Demographics
NPI:1376577627
Name:LIBERTY REGIONAL FOUNDATION, INC.
Entity Type:Organization
Organization Name:LIBERTY REGIONAL FOUNDATION, INC.
Other - Org Name:LIBERTY REGIONAL EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINSTRATIVE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-369-9420
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31310-0115
Mailing Address - Country:US
Mailing Address - Phone:912-369-9420
Mailing Address - Fax:912-368-4258
Practice Address - Street 1:474 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4339
Practice Address - Country:US
Practice Address - Phone:912-369-9420
Practice Address - Fax:912-368-4258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA089-02341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA59RCBNXMedicare PIN