Provider Demographics
NPI:1588747331
Name:CITY OF LIBERTY
Entity type:Organization
Organization Name:CITY OF LIBERTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:DULANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-336-3922
Mailing Address - Street 1:1912 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:TX
Mailing Address - Zip Code:77575-3855
Mailing Address - Country:US
Mailing Address - Phone:936-336-3922
Mailing Address - Fax:936-336-5417
Practice Address - Street 1:1912 LAKELAND
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-7745
Practice Address - Country:US
Practice Address - Phone:936-336-3922
Practice Address - Fax:936-336-5417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1460113416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
505441OtherBLUE CROSS BLUE SHIELD
TX088195501Medicaid
TX=========OtherTAX ID NUMBER
505441OtherBLUE CROSS BLUE SHIELD
TX=========OtherTAX ID NUMBER