Provider Demographics
NPI:1750790960
Name:LIBERTY VILLAGE SENIOR COMMUNITIES INC
Entity type:Organization
Organization Name:LIBERTY VILLAGE SENIOR COMMUNITIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:J MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAEMMERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-799-4447
Mailing Address - Street 1:5920 VENTURE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017
Mailing Address - Country:US
Mailing Address - Phone:614-798-5110
Mailing Address - Fax:614-798-5125
Practice Address - Street 1:1839 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601
Practice Address - Country:US
Practice Address - Phone:740-773-4630
Practice Address - Fax:740-773-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2020 RCF310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH385459727Medicaid
OH2020 RCFOtherRCF LICENSE