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General NPI Number Information
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NPI Number | 1740273663
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Entity Type | Organization
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Legal Business Name | LIBERTY REHABILITATION ASSOCIATES
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Dates
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Enumeration Date | 08/25/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 55 MEADOWLANDS PKWY
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City | SECAUCUS
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State | NJ
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Zip | 07094-2977
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Country | US
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Telephone | 201-392-3231
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Fax | 201-392-3207
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Provider Business Mailing Address
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Address Line | PO BOX 345
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City | WAYNE
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State | NJ
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Zip | 07474-0345
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Country | US
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Telephone | 201-392-3231
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Fax | 201-392-3207
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Authorized Official
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Title or Position | MEDICAL DIRECTOR OF GROP
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Name | DR. JORGE L MAYORAL
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Credential | M.D.
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Telephone | 201-392-3231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | MA068155
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License Number State | NJ
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