Healthcare Provider Details

I. General information

NPI: 1275842254
Provider Name (Legal Business Name): LIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 CARLISLE BLVD NE STE C6
ALBUQUERQUE NM
87107-4565
US

IV. Provider business mailing address

PO BOX 35144
ALBUQUERQUE NM
87176-5144
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-7227
  • Fax: 505-404-7897
Mailing address:
  • Phone: 505-717-7227
  • Fax: 505-404-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05823
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL W. OLLOM
Title or Position: MEMBER
Credential: LISW
Phone: 505-717-7227