Provider Demographics
NPI:1215190905
Name:LIBERTY MEDICAL MINORITY LLC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL MINORITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMBLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-405-5000
Mailing Address - Street 1:831 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8400
Mailing Address - Country:US
Mailing Address - Phone:973-405-5000
Mailing Address - Fax:
Practice Address - Street 1:831 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8400
Practice Address - Country:US
Practice Address - Phone:973-405-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)