Provider Demographics
NPI:1528417003
Name:LIBERTY DIAGNOSTICS
Entity Type:Organization
Organization Name:LIBERTY DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-402-5497
Mailing Address - Street 1:PO BOX 11799
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0799
Mailing Address - Country:US
Mailing Address - Phone:972-402-5497
Mailing Address - Fax:972-755-3748
Practice Address - Street 1:1001 12TH AVE STE 141
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:972-402-5497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory