Provider Demographics
NPI:1598270209
Name:LIVE WELL: UPSTATE CENTER FOR NATURAL HEALTH LLC
Entity Type:Organization
Organization Name:LIVE WELL: UPSTATE CENTER FOR NATURAL HEALTH LLC
Other - Org Name:LIVE WELL UPSTATE
Other - Org Type:Other Name
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAMUS
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:607-733-3373
Mailing Address - Street 1:408 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2603
Mailing Address - Country:US
Mailing Address - Phone:607-733-3373
Mailing Address - Fax:
Practice Address - Street 1:408 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2603
Practice Address - Country:US
Practice Address - Phone:607-733-3373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005959171100000X
NY004530-1171100000X
NY016490-1225700000X
NY029330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1912273574OtherN/A
NY1184137085OtherN/A