Provider Demographics
NPI:1710528211
Name:LIVE WELL CPAP AND MEDICAL SUPPLY
Entity Type:Organization
Organization Name:LIVE WELL CPAP AND MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPSGT
Authorized Official - Phone:208-971-2888
Mailing Address - Street 1:11513 W FAIRVIEW AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-7887
Mailing Address - Country:US
Mailing Address - Phone:208-971-2888
Mailing Address - Fax:
Practice Address - Street 1:11513 W FAIRVIEW AVE STE 103
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7887
Practice Address - Country:US
Practice Address - Phone:208-971-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-05
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies