Provider Demographics
NPI:1043049182
Name:LIVE INDIVIDUATE VIBRATE EVOLVE AND EXPAND - LIVE
Entity type:Organization
Organization Name:LIVE INDIVIDUATE VIBRATE EVOLVE AND EXPAND - LIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-754-3691
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91769-0441
Mailing Address - Country:US
Mailing Address - Phone:909-455-7733
Mailing Address - Fax:866-598-3594
Practice Address - Street 1:1554 SOUT GAREY AVE
Practice Address - Street 2:APT C
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-5244
Practice Address - Country:US
Practice Address - Phone:909-455-7733
Practice Address - Fax:866-598-3594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health