| Live Individuate Vibrate Evolve And Expand - Live | |
|
1554 Sout Garey Ave Apt C Pomona CA 91766-5244 | |
| (909) 455-7733 | |
| (866) 598-3594 |
| Full Name | Live Individuate Vibrate Evolve And Expand - Live |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1554 Sout Garey Ave, Pomona, California |
| Authorized Official Name and Position | Anthony C. Rucker (DIRECTOR) |
| Authorized Official Contact | 9177543691 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Live Individuate Vibrate Evolve And Expand - Live Po Box 441 Pomona CA 91769-0441 Ph: (909) 455-7733 | Live Individuate Vibrate Evolve And Expand - Live 1554 Sout Garey Ave Apt C Pomona CA 91766-5244 Ph: (909) 455-7733 |
| NPI Number | 1043049182 |
|---|---|
| Provider Enumeration Date | 07/29/2024 |
| Last Update Date | 07/29/2024 |
| Certification Date | 07/23/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043049182 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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