Provider Demographics
NPI:1073962114
Name:LIVE YOUNG PLLC
Entity Type:Organization
Organization Name:LIVE YOUNG PLLC
Other - Org Name:LIVE YOUNG CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-212-1111
Mailing Address - Street 1:318 SE FISK RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-8920
Mailing Address - Country:US
Mailing Address - Phone:860-883-5850
Mailing Address - Fax:
Practice Address - Street 1:1680 SW SAINT LUCIE WEST BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1927
Practice Address - Country:US
Practice Address - Phone:772-212-1111
Practice Address - Fax:772-212-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11346261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care