Healthcare Provider Details

I. General information

NPI: 1902349335
Provider Name (Legal Business Name): LIVING WATER HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2016
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 WADE RD SE APT 11
WASHINGTON DC
20020-5906
US

IV. Provider business mailing address

6300 GRENFELL CT
BOWIE MD
20720-5331
US

V. Phone/Fax

Practice location:
  • Phone: 202-460-6876
  • Fax:
Mailing address:
  • Phone: 202-460-6876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. STEPHANIE THOMAS
Title or Position: CEO
Credential:
Phone: 202-460-6876