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General NPI Number Information
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NPI Number | 1730665365
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Entity Type | Organization
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Legal Business Name | LIVEWELL HEALTH SERVICES
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Dates
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Enumeration Date | 07/17/2018
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Last Update Date | 07/17/2018
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Provider Practice Location Address
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Address Line | 1250B AUBURN RD STE 202
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City | DACULA
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State | GA
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Zip | 30019-5433
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Country | US
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Telephone | 678-689-6888
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Fax |
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Provider Business Mailing Address
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Address Line | 1250B AUBURN RD STE 202
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City | DACULA
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State | GA
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Zip | 30019-5433
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Country | US
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Telephone | 678-689-6888
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BERTRAM PROSSER
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Credential |
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Telephone | 678-689-6880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 75651
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License Number State | GA
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