Provider Demographics
NPI:1851353486
Name:LIBERTY HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP, LLC
Other - Org Name:LIBERTY HOMECARE AND HOSPICE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZIZZAMIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:910-815-3122
Mailing Address - Street 1:2334 S 41ST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5502
Mailing Address - Country:US
Mailing Address - Phone:910-815-3122
Mailing Address - Fax:910-815-3111
Practice Address - Street 1:1307 E PINE LOG RD
Practice Address - Street 2:SUITE B
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-9695
Practice Address - Country:US
Practice Address - Phone:803-643-0001
Practice Address - Fax:803-649-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHHA-196251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570371732001OtherBLUE CROSS
SC221827Medicaid
SCC683OtherACM
SCC683OtherACM