Basic Information
| Provider Information | |||||||||
| NPI: | 1992734099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY NURSING CENTER OF PORTSMOUTH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7445 LIBERTY WOODS LN | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454593911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372961550 | ||||||||
| FaxNumber: | 9372961540 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 8TH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403548150 | ||||||||
| FaxNumber: | 7403531826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | BLACK-KUREK | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372961550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3140N1450X | 1899 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 2440915 | 05 | OH | MEDICAID |