Provider Demographics
NPI:1992880462
Name:LIBERTY HOME MEDICAL SUPPLY
Entity type:Organization
Organization Name:LIBERTY HOME MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-844-9669
Mailing Address - Street 1:20509 NORTHVILLE PARK PL
Mailing Address - Street 2:#2006
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2939
Mailing Address - Country:US
Mailing Address - Phone:248-844-9669
Mailing Address - Fax:248-844-9651
Practice Address - Street 1:1904 STAR BATT DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3711
Practice Address - Country:US
Practice Address - Phone:248-844-9669
Practice Address - Fax:248-844-9651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI54OH228090OtherBLUE CROSS BLUE SHIELD
0704610001Medicare ID - Type Unspecified