Provider Demographics
NPI:1457629248
Name:LIBERTY CONNECTION LLC
Entity Type:Organization
Organization Name:LIBERTY CONNECTION LLC
Other - Org Name:LIBERTY CONNECTION LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:601-331-3381
Mailing Address - Street 1:1230 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4583
Mailing Address - Country:US
Mailing Address - Phone:601-331-3381
Mailing Address - Fax:
Practice Address - Street 1:1230 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4583
Practice Address - Country:US
Practice Address - Phone:601-331-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies