Provider Demographics
NPI:1508012105
Name:LIVEWELL MEDICAL INC
Entity Type:Organization
Organization Name:LIVEWELL MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-494-8849
Mailing Address - Street 1:8421 OLD STATESVILLE RD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1808
Mailing Address - Country:US
Mailing Address - Phone:704-494-8849
Mailing Address - Fax:704-494-8850
Practice Address - Street 1:7530 WHITE HORSE ROAD
Practice Address - Street 2:UNIT C
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-2000
Practice Address - Country:US
Practice Address - Phone:864-246-5075
Practice Address - Fax:864-246-5085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVEWELL MEDICAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-14
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE3234Medicaid
NC7705314Medicaid
NC7705314Medicaid