Provider Demographics
NPI:1700956752
Name:LIBERTY HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE GROUP, LLC
Other - Org Name:LIBERTY HOME CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZIZZAMIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:910-815-3122
Mailing Address - Street 1:2334 S 41ST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5502
Mailing Address - Country:US
Mailing Address - Phone:910-815-3122
Mailing Address - Fax:910-815-3111
Practice Address - Street 1:705A WESLEY PINES RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2105
Practice Address - Country:US
Practice Address - Phone:910-738-4512
Practice Address - Fax:910-738-4631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHOS3066251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC007AOtherBLUE CROSS BLUE SHIELD
NC3411569Medicaid
NC341569Medicare ID - Type UnspecifiedPROVIDER NUMBER