Provider Demographics
NPI:1265034227
Name:LIVE LOVE LIFE, INC
Entity Type:Organization
Organization Name:LIVE LOVE LIFE, INC
Other - Org Name:LIVE LOVE LIFE, JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-233-0105
Mailing Address - Street 1:1700 RIDGEWOOD AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-1782
Mailing Address - Country:US
Mailing Address - Phone:585-233-0105
Mailing Address - Fax:386-492-3661
Practice Address - Street 1:1951 BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-3527
Practice Address - Country:US
Practice Address - Phone:904-458-5444
Practice Address - Fax:904-675-3642
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVE LOVE LIFE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-13
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local