Provider Demographics
NPI:1891967329
Name:LIBERTY HEALTH SUPPLIES, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTH SUPPLIES, LLC
Other - Org Name:LIBERTY REHAB & PATIENT AID CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-445-9343
Mailing Address - Street 1:650 MAIN ST # 8
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2829
Mailing Address - Country:US
Mailing Address - Phone:203-445-9343
Mailing Address - Fax:203-445-9312
Practice Address - Street 1:650 MAIN ST # 8
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2829
Practice Address - Country:US
Practice Address - Phone:203-445-9343
Practice Address - Fax:203-445-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0285908000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235728Medicaid
4819510002Medicare NSC