Provider Demographics
NPI:1740698026
Name:LIVE WELL FAMILY MEDICINE PLC
Entity type:Organization
Organization Name:LIVE WELL FAMILY MEDICINE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PERALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-800-3561
Mailing Address - Street 1:655 S DOBSON RD
Mailing Address - Street 2:SUITE B-115
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5667
Mailing Address - Country:US
Mailing Address - Phone:480-800-3561
Mailing Address - Fax:480-800-3562
Practice Address - Street 1:655 S DOBSON RD
Practice Address - Street 2:SUITE B-115
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5667
Practice Address - Country:US
Practice Address - Phone:480-800-3561
Practice Address - Fax:480-800-3562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ508572Medicaid
AZ508572Medicaid