Provider Demographics
NPI:1710426960
Name:THE LIBERTY RANCH REHABILITATION CENTER
Entity Type:Organization
Organization Name:THE LIBERTY RANCH REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-787-0424
Mailing Address - Street 1:2735 KY HIGHWAY 501
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:KY
Mailing Address - Zip Code:40442-9761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2735 KY HIGHWAY 501
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:KY
Practice Address - Zip Code:40442-9761
Practice Address - Country:US
Practice Address - Phone:606-787-0424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder