MEDICARE: LIVE WELL ASSISTED LIVING

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1811527047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE WELL ASSISTED LIVING

Provider Business Mailing Address
First Line	:	6462 S 4TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-7604
Country	:	US
Telephone Number	:	623-399-7824
Fax Number	:

Provider Business Practice Location Address
First Line	:	6462 S 4TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-7604
Country	:	US
Telephone Number	:	623-399-7824
Fax Number	:	855-538-5652

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	DESIRE RUSINGIZWA
Credential	:	BHT
Telephone Number	:	623-877-3764

Provider Enumeration Date	:	01/15/2020
Last Update Date	:	01/15/2020

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Directions to “LIVE WELL ASSISTED LIVING ” Practice Location

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