=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578950739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVING LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 04/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 CANDLEBERRY CT
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-977-4610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 CANDLEBERRY CT
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-977-4610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WALONDA OWENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-977-4610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | HC4740
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------