Basic Information
| Provider Information | |||||||||
| NPI: | 1437253085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALHOUN LIBERTY HOSPITAL ASSOCIATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CALHOUN-LIBERTY HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20370 NE BURNS AVE | ||||||||
| Address2: | PO BOX 419 | ||||||||
| City: | BLOUNTSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324241045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506745411 | ||||||||
| FaxNumber: | 8506741649 | ||||||||
| Practice Location | |||||||||
| Address1: | 20370 NE BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324241045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506745411 | ||||||||
| FaxNumber: | 8506741649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 04/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DARA | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8506475411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 4019 | FL | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 010026900 | 05 | FL | MEDICAID |