Healthcare Provider Details

I. General information

NPI: 1992406128
Provider Name (Legal Business Name): PAUL D LIVE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST PH 11
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

202 12TH ST APT 2
PALISADES PARK NJ
07650-2047
US

V. Phone/Fax

Practice location:
  • Phone: 914-787-3283
  • Fax: 212-304-7050
Mailing address:
  • Phone: 201-207-3819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003108-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: