Provider Demographics
NPI:1144891367
Name:MY DOCTORS LIVE NETWORK
Entity type:Organization
Organization Name:MY DOCTORS LIVE NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:OLLIVIERRE-AGARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-838-8840
Mailing Address - Street 1:170 FITZGERALD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2633
Mailing Address - Country:US
Mailing Address - Phone:800-838-8840
Mailing Address - Fax:
Practice Address - Street 1:170 FITZGERALD RD STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2633
Practice Address - Country:US
Practice Address - Phone:800-838-8840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty