Healthcare Provider Details

I. General information

NPI: 1730665365
Provider Name (Legal Business Name): LIVEWELL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250B AUBURN RD STE 202
DACULA GA
30019-5433
US

IV. Provider business mailing address

1250B AUBURN RD STE 202
DACULA GA
30019-5433
US

V. Phone/Fax

Practice location:
  • Phone: 678-689-6888
  • Fax:
Mailing address:
  • Phone: 678-689-6888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number75651
License Number StateGA

VIII. Authorized Official

Name: BERTRAM PROSSER
Title or Position: OWNER
Credential:
Phone: 678-689-6880