Provider Demographics
NPI:1508040676
Name:LIBERTY HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VIENGKEO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUNEMANY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-747-3356
Mailing Address - Street 1:123 S BROAD ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4304
Mailing Address - Country:US
Mailing Address - Phone:740-503-5933
Mailing Address - Fax:740-901-3028
Practice Address - Street 1:123 S BROAD ST STE 305
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4304
Practice Address - Country:US
Practice Address - Phone:740-901-3026
Practice Address - Fax:740-901-3028
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY HEALTHCARE SERVICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-24
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1588347251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherPASSPORT-WAIVER