=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275155293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY VIVE HEALTH AND FITNESS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2020
-----------------------------------------------------
Last Update Date | 07/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 3RD AVE
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704-5810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-371-3572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 3RD AVE
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704-5810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-371-3572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | BRENT OLIVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-371-3572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------