Basic Information
| Provider Information | |||||||||
| NPI: | 1780012286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIBERTY RESOURCES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTER FOR BRAIN INJURY AND REHABILITATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154251004 | ||||||||
| FaxNumber: | 3154224855 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130452926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072186055 | ||||||||
| FaxNumber: | 6072186059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2013 | ||||||||
| LastUpdateDate: | 10/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3154251004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | 1948L001 | NY | Y | Agencies | In Home Supportive Care |
No ID Information.