=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952815623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE WELL HEALTH AND NUTRITION PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2017
-----------------------------------------------------
Last Update Date | 11/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 N CLOVERDALE RD STE 103
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83713-1067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-392-8383
-----------------------------------------------------
Fax | 208-493-3062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 N CLOVERDALE RD STE 103
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83713-1067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-392-8383
-----------------------------------------------------
Fax | 208-493-3062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP, OWNER
-----------------------------------------------------
Name | DENISE BAHADAR
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 208-861-4677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------