Healthcare Provider Details

I. General information

NPI: 1396168795
Provider Name (Legal Business Name): LIVING WELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 OAK ST
HYDE PARK MA
02136
US

IV. Provider business mailing address

53 OAK ST
HYDE PARK MA
02136
US

V. Phone/Fax

Practice location:
  • Phone: 617-519-8195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMA

VIII. Authorized Official

Name: AUGUSTINA IDAHOR
Title or Position: RN
Credential:
Phone: 617-519-8195