Provider Demographics
NPI:1982369401
Name:LIBERTY FIRST HEALTH
Entity Type:Organization
Organization Name:LIBERTY FIRST HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRACHAR
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:941-777-2775
Mailing Address - Street 1:11882 GRANITE WOODS LOOP
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4116
Mailing Address - Country:US
Mailing Address - Phone:941-416-8781
Mailing Address - Fax:941-214-9709
Practice Address - Street 1:11882 GRANITE WOODS LOOP
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4116
Practice Address - Country:US
Practice Address - Phone:941-416-8781
Practice Address - Fax:941-214-9709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care