Provider Demographics
NPI:1063911683
Name:LIVEUPMEDICAL PLLC
Entity type:Organization
Organization Name:LIVEUPMEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:F
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-285-7227
Mailing Address - Street 1:3000 S HULEN ST STE 124-558
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-1929
Mailing Address - Country:US
Mailing Address - Phone:940-484-0914
Mailing Address - Fax:
Practice Address - Street 1:205 N BONNIE BRAE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-3766
Practice Address - Country:US
Practice Address - Phone:940-384-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty