1972265205 NPI number — DME LIVING WELL, LLC

Table of content: (NPI 1972265205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972265205 NPI number — DME LIVING WELL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DME LIVING WELL, LLC
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:
DME LIVING WELL
Provider Other Organization Name Type Code:
3
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:
1972265205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 COMMERCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06033-2312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-674-1601
Provider Business Mailing Address Fax Number:
508-409-3658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
484 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISKDALE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01518-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-682-5661
Provider Business Practice Location Address Fax Number:
508-409-3658
Provider Enumeration Date:
10/13/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHARAF
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-674-1601

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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