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General NPI Number Information
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NPI Number | 1184221004
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Entity Type | Organization
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Legal Business Name | LIVE IGNITE THRIVE LIMITED
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Dates
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Enumeration Date | 10/04/2020
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Last Update Date | 09/02/2021
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Provider Practice Location Address
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Address Line | 15614 S HARLEM AVE STE C
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City | ORLAND PARK
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State | IL
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Zip | 60462-4401
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Country | US
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Telephone | 708-866-5900
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Fax | 708-866-5903
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Provider Business Mailing Address
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Address Line | 2345 E OFFNER RD
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City | BEECHER
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State | IL
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Zip | 60401-3784
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Country | US
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Telephone | 847-452-6533
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | ADAM WELDZIUS
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Credential |
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Telephone | 847-452-6533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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