Provider Demographics
NPI:1649596784
Name:CALHOUN-LIBERTY HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:CALHOUN-LIBERTY HOSPITAL ASSOCIATION INC
Other - Org Name:CALHOUN-LIBERTY HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-674-5411
Mailing Address - Street 1:20370 NE BURNS AVE
Mailing Address - Street 2:PO BOX 419
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1045
Mailing Address - Country:US
Mailing Address - Phone:850-674-5411
Mailing Address - Fax:850-674-3550
Practice Address - Street 1:20370 NE BURNS AVE
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1045
Practice Address - Country:US
Practice Address - Phone:850-674-5411
Practice Address - Fax:850-674-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4019261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276476800Medicaid
FLAC338Medicare PIN