Provider Demographics
NPI:1306684295
Name:LIVE YOUNG MEDICAL LLC
Entity type:Organization
Organization Name:LIVE YOUNG MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BONHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-681-4829
Mailing Address - Street 1:112 GAUL DR
Mailing Address - Street 2:
Mailing Address - City:SERGEANT BLUFF
Mailing Address - State:IA
Mailing Address - Zip Code:51054-8963
Mailing Address - Country:US
Mailing Address - Phone:402-681-8662
Mailing Address - Fax:
Practice Address - Street 1:112 GAUL DR
Practice Address - Street 2:
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054-8963
Practice Address - Country:US
Practice Address - Phone:402-681-8662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty