Healthcare Provider Details

I. General information

NPI: 1831655406
Provider Name (Legal Business Name): LIVING WELL MANAGEMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W COMMERCIAL BLVD
FORT LAUDERDALE FL
33309-3300
US

IV. Provider business mailing address

3601 W COMMERCIAL BLVD STE 21
FORT LAUDERDALE FL
33309-3320
US

V. Phone/Fax

Practice location:
  • Phone: 954-560-5238
  • Fax:
Mailing address:
  • Phone: 954-909-0407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOEL QUINTERO
Title or Position: CEO
Credential:
Phone: 954-909-0407