Healthcare Provider Details

I. General information

NPI: 1144734252
Provider Name (Legal Business Name): LIVING WELL AT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 RIVERSIDE AVE
FLANDERS NY
11901-3850
US

IV. Provider business mailing address

PO BOX 2177
RIVERHEAD NY
11901-0177
US

V. Phone/Fax

Practice location:
  • Phone: 631-591-0298
  • Fax: 631-740-9233
Mailing address:
  • Phone: 631-591-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: SHANELL LOVETTE WOODLEY
Title or Position: RN CLINICAL COORDINATOR
Credential: RN
Phone: 713-665-9952