MEDICARE: LIVING WELL CENTERS PRIMARY CARE AND BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1427325372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WELL CENTERS PRIMARY CARE AND BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	101 RICE BENT WAY
Second Line	:	SUITE 2
City	:	COLUMBIA
State	:	SC
Zip	:	29229-6849
Country	:	US
Telephone Number	:	803-667-9312
Fax Number	:	803-667-9313

Provider Business Practice Location Address
First Line	:	101 RICE BENT WAY
Second Line	:	SUITE 2
City	:	COLUMBIA
State	:	SC
Zip	:	29229-6849
Country	:	US
Telephone Number	:	803-667-9312
Fax Number	:	803-667-9313

Authorized Official
Title or Position	:	CEO
Name	:	DWAYNE POPE
Credential	:
Telephone Number	:	843-812-5988

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	11/21/2011

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