Organization
LIVE INDIVIDUATE VIBRATE EVOLVE AND EXPAND - LIVE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ANTHONY C. RUCKER (DIRECTOR)
(917) 754-3691
Entity
Organization
Contact information
Practice address
1554 SOUT GAREY AVE, APT C, POMONA, CA 91766-5244
(909) 455-7733
(866) 598-3594
Mailing address
PO BOX 441, POMONA, CA 91769-0441
(909) 455-7733
(866) 598-3594
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
07/29/2024
Last updated
07/29/2024
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