Provider Demographics
NPI:1063766517
Name:LIBERAL INTENSIVE REHABILITATION
Entity type:Organization
Organization Name:LIBERAL INTENSIVE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDES
Authorized Official - Suffix:
Authorized Official - Credentials:MA63008
Authorized Official - Phone:786-300-7706
Mailing Address - Street 1:105 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-4053
Mailing Address - Country:US
Mailing Address - Phone:786-300-7706
Mailing Address - Fax:
Practice Address - Street 1:105 WILSON ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-4053
Practice Address - Country:US
Practice Address - Phone:786-300-7706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA63008261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy