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General NPI Number Information
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NPI Number | 1508125642
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Entity Type | Organization
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Legal Business Name | LIVING WELL ENTERPRISES, LLC
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Dates
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Enumeration Date | 05/10/2012
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 5932 SANDY FORKS RD
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City | RALEIGH
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State | NC
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Zip | 27609-3814
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Country | US
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Telephone | 919-255-2404
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Fax |
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Provider Business Mailing Address
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Address Line | 5616 OLD FORGE CIR
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City | RALEIGH
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State | NC
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Zip | 27609-4032
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Country | US
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Telephone | 919-255-2404
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Fax |
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | JACQUELINE THOMPSON
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Credential |
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Telephone | 919-255-2404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | FCL-092-175
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License Number State | NC
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