Provider Demographics
NPI:1972784734
Name:LIVING WELL FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:LIVING WELL FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERRIN
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:330-726-9355
Mailing Address - Street 1:250 DEBARTOLO PL
Mailing Address - Street 2:SUITE 1650
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-7004
Mailing Address - Country:US
Mailing Address - Phone:330-726-9355
Mailing Address - Fax:330-726-9444
Practice Address - Street 1:250 DEBARTOLO PL
Practice Address - Street 2:SUITE 1650
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-7004
Practice Address - Country:US
Practice Address - Phone:330-726-9355
Practice Address - Fax:330-726-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-95666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF59333Medicare UPIN