Provider Demographics
NPI:1750822540
Name:LIVE OAK AESTHETICS AND WELLNESS
Entity Type:Organization
Organization Name:LIVE OAK AESTHETICS AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-456-2300
Mailing Address - Street 1:8225 YMCA PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-0922
Mailing Address - Country:US
Mailing Address - Phone:225-937-4086
Mailing Address - Fax:225-791-2167
Practice Address - Street 1:8225 YMCA PLAZA DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-0922
Practice Address - Country:US
Practice Address - Phone:225-937-4086
Practice Address - Fax:225-791-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R85966Medicare UPIN