Provider Demographics
NPI:1447428719
Name:LIVING WELL CHRISTIAN FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:LIVING WELL CHRISTIAN FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAMI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:LIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:608-783-1452
Mailing Address - Street 1:575 LESTER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8695
Mailing Address - Country:US
Mailing Address - Phone:608-783-1452
Mailing Address - Fax:
Practice Address - Street 1:575 LESTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8695
Practice Address - Country:US
Practice Address - Phone:608-783-1452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42253100Medicaid