Provider Demographics
NPI:1720332349
Name:LIBERTY HEALTHCARE LLC
Entity type:Organization
Organization Name:LIBERTY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DERK
Authorized Official - Middle Name:
Authorized Official - Last Name:PARDOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-808-2357
Mailing Address - Street 1:3454 E STONE MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-6549
Mailing Address - Country:US
Mailing Address - Phone:801-808-2357
Mailing Address - Fax:
Practice Address - Street 1:5589 GREENWICH RD
Practice Address - Street 2:SUITE 175
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6565
Practice Address - Country:US
Practice Address - Phone:757-216-9115
Practice Address - Fax:757-216-9117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA140177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty