=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598386526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVEWELL HOME HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2020
-----------------------------------------------------
Last Update Date | 04/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11512 N PORT WASHINGTON RD SUITE 201D
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-3440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-375-7051
-----------------------------------------------------
Fax | 262-643-4150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11512 N PORT WASHINGTON RD SUITE 201D
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-3440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-375-7051
-----------------------------------------------------
Fax | 262-643-4150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CORDELIA EKWUEME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-204-6262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------