MEDICARE: LIVING WATER HEALTH AND WELLNESS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225500000X	Respiratory/Developmental/Rehabilitative Specialist/Technologist
2	2255A2300X	Athletic Trainer
3	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1902349335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WATER HEALTH AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	6300 GRENFELL CT
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-5331
Country	:	US
Telephone Number	:	202-460-6876
Fax Number	:

Provider Business Practice Location Address
First Line	:	2636 WADE RD SE APT 11
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-5906
Country	:	US
Telephone Number	:	202-460-6876
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. STEPHANIE THOMAS
Credential	:
Telephone Number	:	202-460-6876

Provider Enumeration Date	:	12/03/2016
Last Update Date	:	01/15/2018

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