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General NPI Number Information
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NPI Number | 1518408939
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Entity Type | Organization
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Legal Business Name | LIVING WATERS CDS, LLC
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Dates
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Enumeration Date | 03/17/2017
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Last Update Date | 03/17/2017
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Provider Practice Location Address
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Address Line | 12632 BROADRIDGE LN
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City | BLACK JACK
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State | MO
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Zip | 63033-4604
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Country | US
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Telephone | 314-540-5238
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Fax |
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Provider Business Mailing Address
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Address Line | 12632 BROADRIDGE LN
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City | BLACK JACK
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State | MO
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Zip | 63033-4604
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | ALVIA J CARROLL
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Credential |
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Telephone | 314-540-5238
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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