Provider Demographics
NPI:1952815623
Name:LIVE WELL HEALTH AND NUTRITION PLLC
Entity Type:Organization
Organization Name:LIVE WELL HEALTH AND NUTRITION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHADAR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-861-4677
Mailing Address - Street 1:4700 N CLOVERDALE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1067
Mailing Address - Country:US
Mailing Address - Phone:208-392-8383
Mailing Address - Fax:208-493-3062
Practice Address - Street 1:4700 N CLOVERDALE RD STE 103
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1067
Practice Address - Country:US
Practice Address - Phone:208-392-8383
Practice Address - Fax:208-493-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP-1169AOtherSTATE LICENSE