Provider Demographics
NPI:1295421709
Name:LOVE GROW LIVE CENTER, INC
Entity type:Organization
Organization Name:LOVE GROW LIVE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURNSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-415-9993
Mailing Address - Street 1:12000 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-7581
Mailing Address - Country:US
Mailing Address - Phone:405-315-9790
Mailing Address - Fax:
Practice Address - Street 1:12000 N VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7581
Practice Address - Country:US
Practice Address - Phone:405-315-9790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities