Provider Demographics
NPI:1477021574
Name:LIVING WELL MEDICAL GROUP
Entity Type:Organization
Organization Name:LIVING WELL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAIRIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-216-5570
Mailing Address - Street 1:344 W 65TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6719
Mailing Address - Country:US
Mailing Address - Phone:786-216-5570
Mailing Address - Fax:
Practice Address - Street 1:344 W 65TH ST STE 201
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6719
Practice Address - Country:US
Practice Address - Phone:786-216-5570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service