Provider Demographics
NPI:1043835424
Name:US LIVE CLINIC LLC
Entity Type:Organization
Organization Name:US LIVE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAFAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-707-1597
Mailing Address - Street 1:12610 E LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-3460
Mailing Address - Country:US
Mailing Address - Phone:480-707-1597
Mailing Address - Fax:
Practice Address - Street 1:12610 E LAUREL LN
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-3460
Practice Address - Country:US
Practice Address - Phone:480-707-1597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty