Provider Demographics
NPI:1194337683
Name:LIBERTY MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:LIBERTY MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-397-5011
Mailing Address - Street 1:1700 N DIXIE HWY STE 116
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1807
Mailing Address - Country:US
Mailing Address - Phone:844-397-5011
Mailing Address - Fax:
Practice Address - Street 1:1700 N DIXIE HWY STE 116
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1807
Practice Address - Country:US
Practice Address - Phone:844-397-5011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies