Provider Demographics
NPI:1871671396
Name:LIQUID BLUE OXYGEN, INC
Entity Type:Organization
Organization Name:LIQUID BLUE OXYGEN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FYOCK
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:814-385-1321
Mailing Address - Street 1:482 DONALDSON RD
Mailing Address - Street 2:
Mailing Address - City:KENNERDELL
Mailing Address - State:PA
Mailing Address - Zip Code:16374-1504
Mailing Address - Country:US
Mailing Address - Phone:814-385-1321
Mailing Address - Fax:814-385-1319
Practice Address - Street 1:482 DONALDSON RD
Practice Address - Street 2:
Practice Address - City:KENNERDELL
Practice Address - State:PA
Practice Address - Zip Code:16374-1504
Practice Address - Country:US
Practice Address - Phone:814-385-1321
Practice Address - Fax:814-385-1319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA8000001243332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5640120001Medicare ID - Type Unspecified