MEDICARE: LIVING WATER COMMUNITY DEVELOPMENT CORPORATION, INC

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	251B00000X	Case Management Agency		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881757938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WATER COMMUNITY DEVELOPMENT CORPORATION, INC

Provider Business Mailing Address
First Line	:	PO BOX 267
Second Line	:
City	:	MOUNT HOLLY
State	:	NC
Zip	:	28120-0267
Country	:	US
Telephone Number	:	704-822-3004
Fax Number	:	704-827-6031

Provider Business Practice Location Address
First Line	:	3906 HICKORY GROVE RD
Second Line	:
City	:	MOUNT HOLLY
State	:	NC
Zip	:	28120-9618
Country	:	US
Telephone Number	:	704-822-3004
Fax Number	:	704-827-6031

Authorized Official
Title or Position	:	CEO
Name	:	DR. ANDREA LENOR GOODING
Credential	:	PHD
Telephone Number	:	704-822-3004

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	08/22/2020

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