Provider Demographics
NPI:1417270752
Name:LIBERTY EYECARE, INC.
Entity Type:Organization
Organization Name:LIBERTY EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LIETTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:513-257-6188
Mailing Address - Street 1:5542 SCHLADE CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-9037
Mailing Address - Country:US
Mailing Address - Phone:513-257-6188
Mailing Address - Fax:513-346-4042
Practice Address - Street 1:1100 E KEMPER RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-3321
Practice Address - Country:US
Practice Address - Phone:513-346-7952
Practice Address - Fax:513-346-4042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH4857152W00000X
OHOH4856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U99610Medicare UPIN
U99611Medicare UPIN