Provider Demographics
NPI:1154633907
Name:LIVE WELL CENTER LLC
Entity Type:Organization
Organization Name:LIVE WELL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-934-9467
Mailing Address - Street 1:8 BIRCHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-1905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 BIRCHWOOD CT
Practice Address - Street 2:
Practice Address - City:UPPER SADDLE RIVER
Practice Address - State:NJ
Practice Address - Zip Code:07458-1905
Practice Address - Country:US
Practice Address - Phone:201-934-9467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00415000103TA0400X, 103TC1900X
NJ25MA07806100207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0140210Medicaid
NJ080853Medicare PIN
NJ0140210Medicaid