Provider Demographics
NPI:1952441222
Name:LIVINGWATERS
Entity Type:Organization
Organization Name:LIVINGWATERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:EALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-717-6127
Mailing Address - Street 1:8419 CARTMAN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8419
Mailing Address - Country:US
Mailing Address - Phone:910-487-2630
Mailing Address - Fax:
Practice Address - Street 1:8383 CLIFFDALE RD.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-5853
Practice Address - Country:US
Practice Address - Phone:910-717-6127
Practice Address - Fax:910-717-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 026-796251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418072Medicaid