MEDICARE: LIVE 4 LIFE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1093066912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE 4 LIFE INC

Provider Business Mailing Address
First Line	:	2911 TURNER RD
Second Line	:	ST B6
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23224-2545
Country	:	US
Telephone Number	:	804-447-7235
Fax Number	:

Provider Business Practice Location Address
First Line	:	2911 TURNER RD
Second Line	:	ST B6
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23224-2545
Country	:	US
Telephone Number	:	804-447-7235
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JASON JACKSON
Credential	:
Telephone Number	:	757-816-7842

Provider Enumeration Date	:	10/02/2012
Last Update Date	:	03/06/2017

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Directions to “LIVE 4 LIFE INC ” Practice Location

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