Provider Demographics
NPI:1710133384
Name:LIBRA FAMILY CARE CENTER PC
Entity Type:Organization
Organization Name:LIBRA FAMILY CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-797-0097
Mailing Address - Street 1:74 BRICK BLVD
Mailing Address - Street 2:BUILDING 4 - SUITE 117
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7984
Mailing Address - Country:US
Mailing Address - Phone:732-797-0097
Mailing Address - Fax:732-797-1880
Practice Address - Street 1:74 BRICK BLVD
Practice Address - Street 2:BUILDIGN 4 - SUITE 117
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7984
Practice Address - Country:US
Practice Address - Phone:732-797-0097
Practice Address - Fax:732-797-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07793400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ140637Medicare PIN