MEDICARE: CATHEDRAL OF LIVING WATERS INC. DBA LIVING WATERS TRANSPORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347C00000X	Private Vehicle
2	164W00000X	Licensed Practical Nurse

General Provider Information

NPI Number	:	1275497778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATHEDRAL OF LIVING WATERS INC. DBA LIVING WATERS TRANSPORT

Provider Business Mailing Address
First Line	:	254 CLINTON AVE APT 2
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07304-1608
Country	:	US
Telephone Number	:	917-830-2539
Fax Number	:

Provider Business Practice Location Address
First Line	:	254 CLINTON AVE APT 2
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07304-1608
Country	:	US
Telephone Number	:	917-830-2539
Fax Number	:

Authorized Official
Title or Position	:	REV.
Name	:	TAYANA ALISHA THOMPSON
Credential	:	REV, LPN. PHD
Telephone Number	:	917-830-5239

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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