Healthcare Provider Details

I. General information

NPI: 1689383671
Provider Name (Legal Business Name): LIVWELL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W BROOME ST
LAGRANGE GA
30240-3102
US

IV. Provider business mailing address

210 W BROOME ST
LAGRANGE GA
30240-3102
US

V. Phone/Fax

Practice location:
  • Phone: 706-668-5140
  • Fax: 706-668-5142
Mailing address:
  • Phone: 706-668-5140
  • Fax: 706-668-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HALEY BUICE
Title or Position: PRACTICE MANAGE
Credential:
Phone: 706-668-5140