Provider Demographics
NPI:1568492874
Name:LIVING WELL FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:LIVING WELL FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRISWOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-951-2750
Mailing Address - Street 1:214 OLD CHAPIN ROAD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-951-2750
Mailing Address - Fax:803-951-3209
Practice Address - Street 1:214 OLD CHAPIN ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-951-2750
Practice Address - Fax:803-951-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
SCSC20418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H16395Medicare UPIN
SCH16395Medicare UPIN
SC7623Medicare ID - Type UnspecifiedGROUP