Provider Demographics
NPI:1689002958
Name:LIFE WELL LIVED SERVICES, INC.
Entity Type:Organization
Organization Name:LIFE WELL LIVED SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:SCHNYEDER
Authorized Official - Middle Name:
Authorized Official - Last Name:DESTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-529-3754
Mailing Address - Street 1:6941 HIGHWAY 92
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3465
Mailing Address - Country:US
Mailing Address - Phone:770-529-3754
Mailing Address - Fax:770-693-8014
Practice Address - Street 1:6941 HIGHWAY 92
Practice Address - Street 2:SUITE 120
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-3465
Practice Address - Country:US
Practice Address - Phone:770-529-3754
Practice Address - Fax:770-693-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA363207706BMedicaid