Provider Demographics
NPI:1639244056
Name:LIBERTY HOUSE
Entity Type:Organization
Organization Name:LIBERTY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-540-0288
Mailing Address - Street 1:2685 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-6548
Mailing Address - Country:US
Mailing Address - Phone:503-540-0288
Mailing Address - Fax:503-540-0293
Practice Address - Street 1:2685 4TH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6548
Practice Address - Country:US
Practice Address - Phone:503-540-0288
Practice Address - Fax:503-540-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067746000OtherBLUE CROSS BLUE SHIELD
OR139463Medicaid