Provider Demographics
NPI:1487012779
Name:LIVINGSTON COMMUNITY HEALTH
Entity Type:Organization
Organization Name:LIVINGSTON COMMUNITY HEALTH
Other - Org Name:WOLVES WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C. E. O.
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:209-394-7913
Mailing Address - Street 1:1140 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1257
Mailing Address - Country:US
Mailing Address - Phone:209-394-7913
Mailing Address - Fax:209-394-9093
Practice Address - Street 1:1617 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1250
Practice Address - Country:US
Practice Address - Phone:209-394-7913
Practice Address - Fax:209-394-3660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVINGSTON COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)