MEDICARE: LIVE LONG WELL CARE, 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1821260779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE LONG WELL CARE, LLC

Provider Business Mailing Address
First Line	:	10706 SIKES PL STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-8015
Country	:	US
Telephone Number	:	704-246-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	48 OSPREY VILLAGE DR
Second Line	:
City	:	AMELIA ISLAND
State	:	FL
Zip	:	32034-4955
Country	:	US
Telephone Number	:	704-246-1616
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DONALD O. THOMPSON
Credential	:
Telephone Number	:	704-246-1616

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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