Provider Demographics
NPI:1326434275
Name:LIVINGLITEMD
Entity Type:Organization
Organization Name:LIVINGLITEMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-C
Authorized Official - Phone:850-814-9223
Mailing Address - Street 1:2507 HARRISON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4424
Mailing Address - Country:US
Mailing Address - Phone:850-215-4455
Mailing Address - Fax:850-215-4492
Practice Address - Street 1:2507 HARRISON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4424
Practice Address - Country:US
Practice Address - Phone:850-215-4455
Practice Address - Fax:850-215-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service