Provider Demographics
NPI:1023121340
Name:LIBERTY DEVELOPMENT COMPANY, LLC
Entity type:Organization
Organization Name:LIBERTY DEVELOPMENT COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:R N
Authorized Official - Phone:208-772-2743
Mailing Address - Street 1:300 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WA
Mailing Address - Zip Code:99111-1971
Mailing Address - Country:US
Mailing Address - Phone:509-397-6123
Mailing Address - Fax:509-397-6367
Practice Address - Street 1:300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-1971
Practice Address - Country:US
Practice Address - Phone:509-397-6123
Practice Address - Fax:509-397-6367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABH 1624310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA865214Medicaid
WABH 1624OtherWA BOARDING HOME PROVIDER