Provider Demographics
NPI:1902208903
Name:LIVE WELL MEDICAL CLINIC & SPA
Entity Type:Organization
Organization Name:LIVE WELL MEDICAL CLINIC & SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:931-839-6642
Mailing Address - Street 1:117 W COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:TN
Mailing Address - Zip Code:38574-1107
Mailing Address - Country:US
Mailing Address - Phone:931-839-6642
Mailing Address - Fax:931-839-6643
Practice Address - Street 1:117 W COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:TN
Practice Address - Zip Code:38574-1107
Practice Address - Country:US
Practice Address - Phone:931-839-6642
Practice Address - Fax:931-839-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007973Medicaid