Provider Demographics
NPI:1144403122
Name:LIVING WATERS COMMUNITY MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:LIVING WATERS COMMUNITY MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-586-2455
Mailing Address - Street 1:13472 VIDALIA RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-8300
Mailing Address - Country:US
Mailing Address - Phone:228-586-2455
Mailing Address - Fax:
Practice Address - Street 1:13472 VIDALIA RD
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-8300
Practice Address - Country:US
Practice Address - Phone:228-586-2455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06960174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015234Medicaid