=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679314694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE EARTH FARM DISCOVERY PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 172 LITCHFIELD LN
-----------------------------------------------------
City | WATSONVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95076-0620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-728-2032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3490
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-728-2032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JESSICA RIDGEWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 831-728-2032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174200000X
-----------------------------------------------------
Taxonomy Name | Meals Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------