MEDICARE: LIVE WELL FOR LIFE, LLC

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	111N00000X	Chiropractor	CH9636	FL

General Provider Information

NPI Number	:	1184850356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE WELL FOR LIFE, LLC

Provider Business Mailing Address
First Line	:	410-9 BLANDING BLVD
Second Line	:	321
City	:	ORANGE PARK
State	:	FL
Zip	:	32073
Country	:	US
Telephone Number	:	904-425-8070
Fax Number	:

Provider Business Practice Location Address
First Line	:	4495 BAYMEADOWS RD STE 9
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4716
Country	:	US
Telephone Number	:	904-425-8070
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICOLE ANZALONE
Credential	:	D.C
Telephone Number	:	904-425-8070

Provider Enumeration Date	:	06/02/2009
Last Update Date	:	06/02/2009

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Directions to “LIVE WELL FOR LIFE, LLC ” Practice Location

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