=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295421709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVE GROW LIVE CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2023
-----------------------------------------------------
Last Update Date | 04/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12000 N VIRGINIA AVE
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73120-7581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-315-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12000 N VIRGINIA AVE
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73120-7581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-315-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM COORDINATOR
-----------------------------------------------------
Name | LESLIE M BURNSIDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-415-9993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------