Provider Demographics
NPI:1780014282
Name:LIBERTY 2000 LLC
Entity Type:Organization
Organization Name:LIBERTY 2000 LLC
Other - Org Name:LIBERTY LABS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:714-306-3013
Mailing Address - Street 1:10760 WARNER AVE
Mailing Address - Street 2:201
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3845
Mailing Address - Country:US
Mailing Address - Phone:714-593-5356
Mailing Address - Fax:714-593-5366
Practice Address - Street 1:10760 WARNER AVE
Practice Address - Street 2:201
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3845
Practice Address - Country:US
Practice Address - Phone:714-593-5356
Practice Address - Fax:714-593-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2057214OtherCLIA