Healthcare Provider Details

I. General information

NPI: 1508630856
Provider Name (Legal Business Name): LIVING WELL MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 SPRUCE ST STE 5
BROOKINGS OR
97415-0407
US

IV. Provider business mailing address

PO BOX 488
BROOKINGS OR
97415-0043
US

V. Phone/Fax

Practice location:
  • Phone: 541-813-1505
  • Fax: 541-813-1506
Mailing address:
  • Phone: 541-813-1505
  • Fax: 541-813-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STACY RAE KREGER
Title or Position: NP/OWNER
Credential: NURSE PRACTITIONER
Phone: 541-813-1505