Provider Demographics
NPI:1700034428
Name:LIVING WATERS VENTURES, INC
Entity Type:Organization
Organization Name:LIVING WATERS VENTURES, INC
Other - Org Name:LIVING WATERS RESIDENTIAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADE
Authorized Official - Middle Name:OLUSOJI
Authorized Official - Last Name:BANKOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-878-6741
Mailing Address - Street 1:1008 LESLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-2912
Mailing Address - Country:US
Mailing Address - Phone:410-878-6741
Mailing Address - Fax:
Practice Address - Street 1:1008 LESLIE AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-2912
Practice Address - Country:US
Practice Address - Phone:410-878-6741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2585251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7405049-00Medicaid