=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396749917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVWELL COMMUNITY HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2005
-----------------------------------------------------
Last Update Date | 07/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1903 BROADWAY ST
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-444-8183
-----------------------------------------------------
Fax | 247-044-8147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1903 BROADWAY ST.
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-444-8183
-----------------------------------------------------
Fax | 270-933-1969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DONNA REEDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-444-8183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------