MEDICARE: LIVING WELL MEDICAL PRACTICE LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1538781455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WELL MEDICAL PRACTICE LLC

Provider Business Mailing Address
First Line	:	7136 S MILITARY TRL STE 10
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7812
Country	:	US
Telephone Number	:	561-358-1722
Fax Number	:

Provider Business Practice Location Address
First Line	:	7136 S MILITARY TRL STE 10
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7812
Country	:	US
Telephone Number	:	561-358-1722
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOAN WILLIAMSON
Credential	:	ARNP
Telephone Number	:	561-358-1722

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	11/24/2020

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