Healthcare Provider Details

I. General information

NPI: 1467763664
Provider Name (Legal Business Name): LIBERATION FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 E 4TH ST
PALMYRA NJ
08065-1506
US

IV. Provider business mailing address

218 E 4TH ST
PALMYRA NJ
08065-1506
US

V. Phone/Fax

Practice location:
  • Phone: 856-786-4875
  • Fax:
Mailing address:
  • Phone: 856-786-4875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN BROWN
Title or Position: PRESIDENT
Credential: C..P.T.,N.C
Phone: 856-786-4875