Healthcare Provider Details

I. General information

NPI: 1124729090
Provider Name (Legal Business Name): MAKEBA LIVINGSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 03/16/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 AUGUSTINE ST
ROCHESTER NY
14613-1311
US

IV. Provider business mailing address

1860 SANDY PLAINS RD STE 204
MARIETTA GA
30066-7864
US

V. Phone/Fax

Practice location:
  • Phone: 585-465-3738
  • Fax:
Mailing address:
  • Phone: 585-465-3738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: