Provider Demographics
NPI:1962603142
Name:LIBERTY HEALTHCARE SYSTEMS
Entity type:Organization
Organization Name:LIBERTY HEALTHCARE SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RADIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-251-9458
Mailing Address - Street 1:4673 EUGENE WARE BLVD
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-1425
Mailing Address - Country:US
Mailing Address - Phone:318-281-2448
Mailing Address - Fax:318-281-2499
Practice Address - Street 1:4673 EUGENE WARE BLVD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-1425
Practice Address - Country:US
Practice Address - Phone:318-281-2448
Practice Address - Fax:318-281-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA573283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1453676Medicaid