1689095192 NPI number — LIVING WELL COMMUNITY, LLC

Table of content: (NPI 1174311195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689095192 NPI number — LIVING WELL COMMUNITY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING WELL COMMUNITY, 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:
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:
1689095192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 JOHN MOORE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-6333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-661-7186
Provider Business Mailing Address Fax Number:
813-662-4324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 JOHN MOORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-6333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-661-7186
Provider Business Practice Location Address Fax Number:
813-662-4324
Provider Enumeration Date:
12/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
SHERROD
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
813-494-0643

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  AL11733 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 014282800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com