Provider Demographics
NPI:1235527250
Name:LIVE WELL MEDICAL SUPPLIES, INC
Entity Type:Organization
Organization Name:LIVE WELL MEDICAL SUPPLIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KIETH
Authorized Official - Last Name:SIRKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-656-3700
Mailing Address - Street 1:7338 SYCAMORE CANYON BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-2334
Mailing Address - Country:US
Mailing Address - Phone:951-656-3700
Mailing Address - Fax:951-697-5866
Practice Address - Street 1:7338 SYCAMORE CANYON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-2334
Practice Address - Country:US
Practice Address - Phone:951-656-3700
Practice Address - Fax:951-697-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1230445343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
6685180001Medicare NSC