Provider Demographics
NPI:1083203608
Name:LIBRA SUITES
Entity Type:Organization
Organization Name:LIBRA SUITES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-383-5753
Mailing Address - Street 1:460 E FORDHAM RD # 2032
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5108
Mailing Address - Country:US
Mailing Address - Phone:347-780-4853
Mailing Address - Fax:
Practice Address - Street 1:460 E FORDHAM RD # 2032
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5108
Practice Address - Country:US
Practice Address - Phone:347-780-4853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory