Provider Demographics
NPI:1932257375
Name:LIBERTY III MANAGEMENT TR
Entity Type:Organization
Organization Name:LIBERTY III MANAGEMENT TR
Other - Org Name:PROFESSIONAL MEDICAL OXYGEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:623-587-0012
Mailing Address - Street 1:PO BOX 86658
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-6658
Mailing Address - Country:US
Mailing Address - Phone:602-509-2001
Mailing Address - Fax:623-587-7533
Practice Address - Street 1:21620 N 19TH AVE
Practice Address - Street 2:A102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-2716
Practice Address - Country:US
Practice Address - Phone:623-587-0012
Practice Address - Fax:623-587-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07498747M332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0994420001Medicare ID - Type UnspecifiedMEDICARE ID#