Healthcare Provider Details

I. General information

NPI: 1851657886
Provider Name (Legal Business Name): LIBERTY SPINE AND PAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 W END AVE APT 22B
NEW YORK NY
10023-2617
US

IV. Provider business mailing address

PO BOX 3837
CAROL STREAM IL
60132-3837
US

V. Phone/Fax

Practice location:
  • Phone: 214-615-5168
  • Fax: 888-526-9542
Mailing address:
  • Phone: 214-615-5168
  • Fax: 888-526-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0400479905
License Number StateNJ

VIII. Authorized Official

Name: MR. NICK LLOYD
Title or Position: VP OF ATHAS
Credential:
Phone: 214-615-5168