Provider Demographics
NPI:1689095192
Name:LIVING WELL COMMUNITY, LLC
Entity Type:Organization
Organization Name:LIVING WELL COMMUNITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SHERROD
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-494-0643
Mailing Address - Street 1:2222 JOHN MOORE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6333
Mailing Address - Country:US
Mailing Address - Phone:813-661-7186
Mailing Address - Fax:813-662-4324
Practice Address - Street 1:2222 JOHN MOORE RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6333
Practice Address - Country:US
Practice Address - Phone:813-661-7186
Practice Address - Fax:813-662-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11733251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management