Provider Demographics
NPI:1649718677
Name:LIBERTY HOUSING SERVICE
Entity type:Organization
Organization Name:LIBERTY HOUSING SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-875-5479
Mailing Address - Street 1:17602 17TH ST STE 102-123
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1961
Mailing Address - Country:US
Mailing Address - Phone:714-875-5479
Mailing Address - Fax:
Practice Address - Street 1:13832 GLENMERE DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-2812
Practice Address - Country:US
Practice Address - Phone:714-332-3143
Practice Address - Fax:714-486-2127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300249BP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility