Healthcare Provider Details

I. General information

NPI: 1235751272
Provider Name (Legal Business Name): LIBERTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 GREGORY AVE
WEST ORANGE NJ
07052-4713
US

IV. Provider business mailing address

60 GREGORY AVE
WEST ORANGE NJ
07052-4713
US

V. Phone/Fax

Practice location:
  • Phone: 201-306-5443
  • Fax:
Mailing address:
  • Phone: 201-306-5443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number
License Number State

VIII. Authorized Official

Name: MR. FRANK C LOMBARDO JR.
Title or Position: AUDIOLOGIST
Credential: MA-CCC A
Phone: 201-498-1207