Provider Demographics
NPI:1508338708
Name:LIBERTY PROVIDER LLC
Entity Type:Organization
Organization Name:LIBERTY PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:BRUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-344-7331
Mailing Address - Street 1:7110 W CENTRAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-3118
Mailing Address - Country:US
Mailing Address - Phone:419-517-7000
Mailing Address - Fax:
Practice Address - Street 1:7110 W CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-3118
Practice Address - Country:US
Practice Address - Phone:419-517-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health