Provider Demographics
NPI:1134892201
Name:LIVE OAK FAMILY PRACTICE, LLC
Entity type:Organization
Organization Name:LIVE OAK FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:F
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:386-688-7813
Mailing Address - Street 1:10061 COUNTY ROAD 49
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-7686
Mailing Address - Country:US
Mailing Address - Phone:386-688-7813
Mailing Address - Fax:
Practice Address - Street 1:1304 OHIO AVE S
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4156
Practice Address - Country:US
Practice Address - Phone:386-364-0776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty