Healthcare Provider Details

I. General information

NPI: 1972152908
Provider Name (Legal Business Name): LIVING LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 SOUTHLAKE BLVD SUITE B
NORTH CHESTERFIELD VA
23236-4942
US

IV. Provider business mailing address

7305 HANCOCK VILLAGE DR PO BOX 124
CHESTERFIELD VA
23832-1369
US

V. Phone/Fax

Practice location:
  • Phone: 757-696-1806
  • Fax:
Mailing address:
  • Phone: 804-307-4589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: ERICA JACKSON
Title or Position: OWNER
Credential:
Phone: 757-696-1806