Provider Demographics
NPI:1003812728
Name:LIBERTY CHILD AND ADOLESCENT HEALTH SERVICES
Entity Type:Organization
Organization Name:LIBERTY CHILD AND ADOLESCENT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BONFORTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-714-7903
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-0334
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:550 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1326
Practice Address - Country:US
Practice Address - Phone:201-714-7902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6697704Medicaid
NJ6697704Medicaid