Provider Demographics
NPI:1104295583
Name:LIBERTY HOUSE LLC
Entity type:Organization
Organization Name:LIBERTY HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:PAL
Authorized Official - Last Name:REGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-460-4137
Mailing Address - Street 1:9314 FOREST HILL BLVD
Mailing Address - Street 2:313
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9314 FOREST HILL BLVD
Practice Address - Street 2:313
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33411-6577
Practice Address - Country:US
Practice Address - Phone:561-460-4137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10D2099701261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder