Healthcare Provider Details

I. General information

NPI: 1144593021
Provider Name (Legal Business Name): LIVING WELL PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DEVANT ST SUITE 902
FAYETTEVILLE GA
30214-2710
US

IV. Provider business mailing address

101 DEVANT ST SUITE 902
FAYETTEVILLE GA
30214-2710
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-8228
  • Fax: 770-716-6588
Mailing address:
  • Phone: 770-716-8228
  • Fax: 770-716-6588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JONES
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 803-807-9533