Provider Demographics
NPI:1609026798
Name:LIVING WELL MEDICAL SUPPORT LLC
Entity Type:Organization
Organization Name:LIVING WELL MEDICAL SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:T C
Authorized Official - Last Name:PENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-251-6781
Mailing Address - Street 1:214 HIDDEN WOODS CT
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-3060
Mailing Address - Country:US
Mailing Address - Phone:561-251-6781
Mailing Address - Fax:561-994-3549
Practice Address - Street 1:78 EASTON AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1885
Practice Address - Country:US
Practice Address - Phone:732-828-1003
Practice Address - Fax:732-828-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05520200302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJA62798Medicare UPIN