Provider Demographics
NPI:1053475780
Name:LIVING WELL CENTRE
Entity Type:Organization
Organization Name:LIVING WELL CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:DELICE
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:919-489-2254
Mailing Address - Street 1:1804 MLK JR. PARKWAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3587
Mailing Address - Country:US
Mailing Address - Phone:919-489-2254
Mailing Address - Fax:919-403-1551
Practice Address - Street 1:1804 MLK JR. PARKWAY
Practice Address - Street 2:SUITE 210
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3587
Practice Address - Country:US
Practice Address - Phone:919-489-2254
Practice Address - Fax:919-403-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300257Medicaid