Provider Demographics
NPI:1134460165
Name:LIVING WELL MEDICAL CENTER
Entity Type:Organization
Organization Name:LIVING WELL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-357-0586
Mailing Address - Street 1:9150 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1364
Mailing Address - Country:US
Mailing Address - Phone:913-341-9797
Mailing Address - Fax:
Practice Address - Street 1:9150 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1364
Practice Address - Country:US
Practice Address - Phone:913-341-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty