Provider Demographics
NPI:1508630856
Name:LIVING WELL MEDICAL, LLC
Entity Type:Organization
Organization Name:LIVING WELL MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:KREGER
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:541-813-1505
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0043
Mailing Address - Country:US
Mailing Address - Phone:541-813-1505
Mailing Address - Fax:541-813-1506
Practice Address - Street 1:524 SPRUCE ST STE 5
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-0407
Practice Address - Country:US
Practice Address - Phone:541-813-1505
Practice Address - Fax:541-813-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty