Provider Demographics
NPI:1366603243
Name:LIBERTY ASSISTED LIVING
Entity type:Organization
Organization Name:LIBERTY ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARSONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-324-7300
Mailing Address - Street 1:5890 CYPRESS GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-2274
Mailing Address - Country:US
Mailing Address - Phone:863-324-7300
Mailing Address - Fax:863-324-6231
Practice Address - Street 1:5890 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-2274
Practice Address - Country:US
Practice Address - Phone:863-324-7300
Practice Address - Fax:863-324-6231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7713310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL673114700Medicaid