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General NPI Number Information
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NPI Number | 1881757938
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Entity Type | Organization
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Legal Business Name | LIVING WATER COMMUNITY DEVELOPMENT CORPORATION, INC
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Dates
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Enumeration Date | 12/19/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3906 HICKORY GROVE RD
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City | MOUNT HOLLY
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State | NC
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Zip | 28120-9618
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Country | US
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Telephone | 704-822-3004
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Fax | 704-827-6031
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Provider Business Mailing Address
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Address Line | PO BOX 267
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City | MOUNT HOLLY
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State | NC
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Zip | 28120-0267
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Country | US
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Telephone | 704-822-3004
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Fax | 704-827-6031
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Authorized Official
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Title or Position | CEO
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Name | DR. ANDREA LENOR GOODING
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Credential | PHD
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Telephone | 704-822-3004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | NC
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