Healthcare Provider Details

I. General information

NPI: 1770675886
Provider Name (Legal Business Name): LIVEWELL MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 EL CAMINO REAL #225
SAN BRUNO CA
94066
US

IV. Provider business mailing address

5528 PACHECO BLVD STE A
PACHECO CA
94553
US

V. Phone/Fax

Practice location:
  • Phone: 650-873-3338
  • Fax: 650-873-3308
Mailing address:
  • Phone: 925-363-8170
  • Fax: 925-363-4995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA78723
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG78328
License Number StateCA

VIII. Authorized Official

Name: MARIA LUISA OSMONA
Title or Position: PRESIDENT OWNER
Credential: MD
Phone: 650-873-3338