Provider Demographics
NPI:1902855729
Name:LIBERTY HEALTH SUPPLY, INC
Entity Type:Organization
Organization Name:LIBERTY HEALTH SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-235-1370
Mailing Address - Street 1:1099 JAY ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-1153
Mailing Address - Country:US
Mailing Address - Phone:585-235-1370
Mailing Address - Fax:585-235-1385
Practice Address - Street 1:1099 JAY ST
Practice Address - Street 2:SUITE E
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-1153
Practice Address - Country:US
Practice Address - Phone:585-235-1370
Practice Address - Fax:585-235-1385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1302050Medicaid
NYLHE109146OtherEXCELLUS PROVIDER #
NY8201631OtherEVERCARE
NY02068413Medicaid
NY103644OtherPREFERRED CARE PROVIDER #
NYP0170059CMOtherBLUE CHOICE PROVIDER #
NYLHE109146OtherEXCELLUS PROVIDER #