MEDICARE: LOVE GROW LIVE CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	252Y00000X	Early Intervention Provider Agency
3	261QD1600X	Developmental Disabilities Clinic/Center
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1295421709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOVE GROW LIVE CENTER, INC

Provider Business Mailing Address
First Line	:	12000 N VIRGINIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7581
Country	:	US
Telephone Number	:	405-315-9790
Fax Number	:

Provider Business Practice Location Address
First Line	:	12000 N VIRGINIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7581
Country	:	US
Telephone Number	:	405-315-9790
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM COORDINATOR
Name	:	LESLIE M BURNSIDE
Credential	:
Telephone Number	:	870-415-9993

Provider Enumeration Date	:	04/17/2023
Last Update Date	:	04/17/2023

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Directions to “LOVE GROW LIVE CENTER, INC ” Practice Location

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