Provider Demographics
NPI:1518138155
Name:LIBERTY HEALTH SUPPLIES, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTH SUPPLIES, LLC
Other - Org Name:LIBERTY REHAB & PATIENT AID CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-452-5599
Mailing Address - Street 1:1151 STRATFORD AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-6312
Mailing Address - Country:US
Mailing Address - Phone:203-452-5599
Mailing Address - Fax:203-459-2860
Practice Address - Street 1:1151 STRATFORD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-6312
Practice Address - Country:US
Practice Address - Phone:203-452-5599
Practice Address - Fax:203-459-2860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0285908000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4819510001Medicare NSC