Organization
CITY OF LIBERTY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MISTY LEIGH DULANEY (ADMINISTRATIVE ASSISTANT)
(936) 336-3922
Entity
Organization
Contact information
Practice address
1912 LAKELAND, LIBERTY, TX 77575-7745
(936) 336-3922
(936) 336-5417
Mailing address
1912 LAKELAND DR, LIBERTY, TX 77575-3855
(936) 336-3922
(936) 336-5417
Taxonomy
Speciality
Code
Description
License number
State
3416L0300X
Land Ambulance
Primary
146011
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
088195501
—
TX
01
—
505441
BLUE CROSS BLUE SHIELD
—
Enumeration date
10/23/2006
Last updated
01/12/2010
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