Basic Information
| Provider Information | |||||||||
| NPI: | 1639729452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY RESOURCES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154251004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154724471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2019 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | KELLI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3154251004 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIBERTY RESOURCES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 02994810 | 05 | NY | MEDICAID |