Healthcare Provider Details

I. General information

NPI: 1063766517
Provider Name (Legal Business Name): LIBERAL INTENSIVE REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WILSON ST
LIBERAL KS
67901-4053
US

IV. Provider business mailing address

105 WILSON ST
LIBERAL KS
67901-4053
US

V. Phone/Fax

Practice location:
  • Phone: 786-300-7706
  • Fax:
Mailing address:
  • Phone: 786-300-7706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberMA63008
License Number StateFL

VIII. Authorized Official

Name: CARLOS MENDES
Title or Position: OWNER/MANAGER
Credential: MA63008
Phone: 786-300-7706