Provider Demographics
NPI:1316010960
Name:LIVELO, EDITH C (ABOC, RDO)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:C
Last Name:LIVELO
Suffix:
Gender:F
Credentials:ABOC, RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 S SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3803
Mailing Address - Country:US
Mailing Address - Phone:650-343-5151
Mailing Address - Fax:650-343-5178
Practice Address - Street 1:21 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3803
Practice Address - Country:US
Practice Address - Phone:650-343-5151
Practice Address - Fax:650-343-5178
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD 6765156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX006765FMedicaid