Healthcare Provider Details

I. General information

NPI: 1205971330
Provider Name (Legal Business Name): VICTOR LIBERI ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 COLLEGE AVE. UNIVERSITY OF SO. MAINE
GORHAM ME
04038
US

IV. Provider business mailing address

25 LAUREL PINES DR
GORHAM ME
04038-1654
US

V. Phone/Fax

Practice location:
  • Phone: 207-228-8206
  • Fax:
Mailing address:
  • Phone: 207-228-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT211
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: