Healthcare Provider Details

I. General information

NPI: 1669171369
Provider Name (Legal Business Name): LIVING WELL PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 OLMSTED BLVD UNIT 3, STE 5
PINEHURST NC
28374-8730
US

IV. Provider business mailing address

370 OAKHURST VISTA
WEST END NC
27376
US

V. Phone/Fax

Practice location:
  • Phone: 910-541-5880
  • Fax: 910-240-9469
Mailing address:
  • Phone: 816-200-4491
  • Fax: 910-240-9469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. WARREN CHARLES JOHNSON III
Title or Position: CEO
Credential: MD
Phone: 816-200-4491