Provider Demographics
NPI:1740768464
Name:UPSTATE LIVING WATER, LLC
Entity Type:Organization
Organization Name:UPSTATE LIVING WATER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ORVILLE
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HOGANCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-569-5977
Mailing Address - Street 1:340 BLAKELY AVE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-9309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50A PARKINS MILL RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2930
Practice Address - Country:US
Practice Address - Phone:864-569-5977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCIHCP-0754Medicaid