1861963050 NPI number — LIVING HEALTHY WELLNESS CENTER

Table of content: (NPI 1447386628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861963050 NPI number — LIVING HEALTHY WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING HEALTHY WELLNESS CENTER
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:
6
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:
1861963050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 W OLD HICKORY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37115-3653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-454-2016
Provider Business Mailing Address Fax Number:
615-454-2507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 W OLD HICKORY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37115-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-456-2016
Provider Business Practice Location Address Fax Number:
615-454-2507
Provider Enumeration Date:
12/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMES
Authorized Official First Name:
JOY
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
615-454-2016

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q044948 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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