Provider Demographics
NPI:1730665365
Name:LIVEWELL HEALTH SERVICES
Entity Type:Organization
Organization Name:LIVEWELL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-689-6880
Mailing Address - Street 1:1250B AUBURN RD STE 202
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5433
Mailing Address - Country:US
Mailing Address - Phone:678-689-6888
Mailing Address - Fax:
Practice Address - Street 1:1250B AUBURN RD STE 202
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5433
Practice Address - Country:US
Practice Address - Phone:678-689-6888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty