Provider Demographics
NPI:1467763664
Name:LIBERATION FITNESS
Entity Type:Organization
Organization Name:LIBERATION FITNESS
Other - Org Name:LIBERATION WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPT,NC
Authorized Official - Phone:856-786-4875
Mailing Address - Street 1:218 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NJ
Mailing Address - Zip Code:08065-1506
Mailing Address - Country:US
Mailing Address - Phone:856-786-4875
Mailing Address - Fax:
Practice Address - Street 1:218 E 4TH ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NJ
Practice Address - Zip Code:08065-1506
Practice Address - Country:US
Practice Address - Phone:856-786-4875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty