Provider Demographics
NPI:1740562081
Name:LIVINGSTON, FARGO MICHAEL (BA)
Entity Type:Individual
Prefix:MR
First Name:FARGO
Middle Name:MICHAEL
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291
Mailing Address - Country:US
Mailing Address - Phone:310-399-9883
Mailing Address - Fax:
Practice Address - Street 1:717 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2845
Practice Address - Country:US
Practice Address - Phone:310-399-9883
Practice Address - Fax:131-039-9967
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker