Provider Demographics
NPI:1013640242
Name:LIVING WELL PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:LIVING WELL PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:PENNINGTON
Authorized Official - Last Name:MCNICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-819-7660
Mailing Address - Street 1:12460 CRABAPPLE RD STE 202-313
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6602
Mailing Address - Country:US
Mailing Address - Phone:404-819-7660
Mailing Address - Fax:404-393-7788
Practice Address - Street 1:12460 CRABAPPLE RD STE 202-313
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6602
Practice Address - Country:US
Practice Address - Phone:404-819-7660
Practice Address - Fax:404-393-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care