1144734252 NPI number — LIVING WELL AT HOME

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 1144734252 NPI number — LIVING WELL AT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING WELL AT HOME
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:
1144734252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2177
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERHEAD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11901-0177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-591-0298
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 RIVERSIDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLANDERS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11901-3850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-591-0298
Provider Business Practice Location Address Fax Number:
631-740-9233
Provider Enumeration Date:
11/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WOODLEY
Authorized Official First Name:
SHANELL
Authorized Official Middle Name:
LOVETTE
Authorized Official Title or Position:
RN CLINICAL COORDINATOR
Authorized Official Telephone Number:
713-665-9952

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1902324502 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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