Provider Demographics
NPI:1962507814
Name:LIVEWELL MEDICAL INC
Entity Type:Organization
Organization Name:LIVEWELL MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-494-8849
Mailing Address - Street 1:8421 OLD STATESVILLE RD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1808
Mailing Address - Country:US
Mailing Address - Phone:704-494-8849
Mailing Address - Fax:704-494-8850
Practice Address - Street 1:8421 OLD STATESVILLE RD
Practice Address - Street 2:SUITE 18
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1808
Practice Address - Country:US
Practice Address - Phone:704-494-8849
Practice Address - Fax:704-494-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7705319Medicaid
SCDE2703Medicaid
NC7705319Medicaid