Healthcare Provider Details

I. General information

NPI: 1205173952
Provider Name (Legal Business Name): LIVING WELL IN COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6284 RUCKER RD SUITE N
INDIANAPOLIS IN
46220-4865
US

IV. Provider business mailing address

6284 RUCKER RD SUITE N
INDIANAPOLIS IN
46220-4865
US

V. Phone/Fax

Practice location:
  • Phone: 317-475-1389
  • Fax: 317-475-9089
Mailing address:
  • Phone: 317-475-1389
  • Fax: 317-475-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34002279A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05000996A
License Number StateIN

VIII. Authorized Official

Name: MR. PAUL NELSON GEORGE
Title or Position: PRESIDENT
Credential: M.S., L.C.S.W.
Phone: 317-475-1389