Provider Demographics
NPI:1992019640
Name:LIVE WELL M.D.
Entity Type:Organization
Organization Name:LIVE WELL M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-807-9747
Mailing Address - Street 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:BUILDING 521
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9680
Mailing Address - Country:US
Mailing Address - Phone:904-807-9747
Mailing Address - Fax:904-807-9746
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:BUILDING 521
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-807-9747
Practice Address - Fax:904-807-9746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization