Healthcare Provider Details

I. General information

NPI: 1750822540
Provider Name (Legal Business Name): LIVE OAK AESTHETICS AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 YMCA PLAZA DR
BATON ROUGE LA
70810-0922
US

IV. Provider business mailing address

8225 YMCA PLAZA DR
BATON ROUGE LA
70810-0922
US

V. Phone/Fax

Practice location:
  • Phone: 225-937-4086
  • Fax: 225-791-2167
Mailing address:
  • Phone: 225-937-4086
  • Fax: 225-791-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: ELIZABETH M JONES
Title or Position: OFFICE MANAGER
Credential:
Phone: 225-456-2300