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General NPI Number Information
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NPI Number | 1336408517
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Entity Type | Organization
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Legal Business Name | LIVING WELL HEALTH MANAGEMENT INC
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Dates
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Enumeration Date | 05/09/2012
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Last Update Date | 05/09/2012
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Provider Practice Location Address
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Address Line | 4150 S BERKELEY AVE
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City | CHICAGO
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State | IL
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Zip | 60653-3010
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Country | US
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Telephone | 773-285-9100
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Fax | 773-451-2770
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Provider Business Mailing Address
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Address Line | 4150 S BERKELEY AVE
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City | CHICAGO
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State | IL
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Zip | 60653-3010
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Country | US
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Telephone | 773-285-9100
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Fax | 773-451-2770
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Authorized Official
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Title or Position | PRESIDENT
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Name | IDA M DIXON
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Credential |
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Telephone | 773-285-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 209009287
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License Number State | IL
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