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General NPI Number Information
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NPI Number | 1780999755
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Entity Type | Organization
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Legal Business Name | LIBERTY PHYSICAL MEDICINE & REHAB
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Dates
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Enumeration Date | 08/13/2010
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Last Update Date | 08/13/2010
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Provider Practice Location Address
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Address Line | 3755 77TH ST SUITE 1J
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-6603
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Country | US
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Telephone | 718-651-8414
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Fax |
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Provider Business Mailing Address
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Address Line | 3755 77TH ST SUITE 1J
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-6603
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Country | US
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Telephone | 718-651-8414
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ELYSE CHANG
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Credential |
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Telephone | 718-651-8414
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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 | 241442
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License Number State | NY
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