MEDICARE: LIVE WELL RECOVERY CENTER 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1285203711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE WELL RECOVERY CENTER INC

Provider Business Mailing Address
First Line	:	6041 FAIR AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-4230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6041 FAIR AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-4230
Country	:	US
Telephone Number	:	818-601-5225
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ARMEN ANTONYAN
Credential	:
Telephone Number	:	818-601-5225

Provider Enumeration Date	:	06/19/2021
Last Update Date	:	06/19/2021

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