Provider Demographics
NPI:1518569573
Name:LIVE LOVE LIFE, INC
Entity Type:Organization
Organization Name:LIVE LOVE LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-478-8219
Mailing Address - Street 1:5000 WEST COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-7602
Mailing Address - Country:US
Mailing Address - Phone:407-291-1236
Mailing Address - Fax:407-291-1797
Practice Address - Street 1:5000 WEST COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-7602
Practice Address - Country:US
Practice Address - Phone:407-291-1236
Practice Address - Fax:407-291-1797
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:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health