Healthcare Provider Details

I. General information

NPI: 1013640242
Provider Name (Legal Business Name): LIVING WELL PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12460 CRABAPPLE RD STE 202-313
ALPHARETTA GA
30004-6602
US

IV. Provider business mailing address

12460 CRABAPPLE RD STE 202-313
ALPHARETTA GA
30004-6602
US

V. Phone/Fax

Practice location:
  • Phone: 404-819-7660
  • Fax: 404-393-7788
Mailing address:
  • Phone: 404-819-7660
  • Fax: 404-393-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LEE PENNINGTON MCNICHOLS
Title or Position: OWNER/MANAGING MEMBER
Credential: NP
Phone: 404-819-7660