1699516534 NPI number — LIVING WATER RESIDENTIAL SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699516534 NPI number — LIVING WATER RESIDENTIAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING WATER RESIDENTIAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699516534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7563
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71211-7563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-278-5964
Provider Business Mailing Address Fax Number:
318-343-7125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 SPURGEON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71203-4521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-614-7644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PRINGLE
Authorized Official First Name:
LASHUNTA
Authorized Official Middle Name:
SHARLAN
Authorized Official Title or Position:
ADMIN. CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
318-278-5964

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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