Healthcare Provider Details

I. General information

NPI: 1265034227
Provider Name (Legal Business Name): LIVE LOVE LIFE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 BOULEVARD
JACKSONVILLE FL
32206-3527
US

IV. Provider business mailing address

1700 RIDGEWOOD AVE SUITE I
HOLLY HILL FL
32117-1782
US

V. Phone/Fax

Practice location:
  • Phone: 904-640-7954
  • Fax: 386-272-7938
Mailing address:
  • Phone: 585-233-0105
  • Fax: 386-492-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK A. WALCZYK
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 585-233-0105