Healthcare Provider Details

I. General information

NPI: 1427969963
Provider Name (Legal Business Name): LIVEABETES CLINIC SC1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 HIGHWAY 153 STE DM
PIEDMONT SC
29673-9498
US

IV. Provider business mailing address

3150 HIGHWAY 153 STE DM
PIEDMONT SC
29673-9498
US

V. Phone/Fax

Practice location:
  • Phone: 949-201-9245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SAVANNAH JOCHUM
Title or Position: CREDENTIALER
Credential:
Phone: 949-201-9245