Provider Demographics
NPI:1568949758
Name:LIBERTY MOBILE LABS INC
Entity Type:Organization
Organization Name:LIBERTY MOBILE LABS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:AMCA-PCT 4709
Authorized Official - Phone:630-880-9517
Mailing Address - Street 1:541 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2504
Mailing Address - Country:US
Mailing Address - Phone:630-880-9517
Mailing Address - Fax:630-596-1404
Practice Address - Street 1:541 SPRUCE RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2504
Practice Address - Country:US
Practice Address - Phone:630-880-9454
Practice Address - Fax:630-596-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No253Z00000XAgenciesIn Home Supportive Care