Provider Demographics
NPI:1134829567
Name:LIVING WELL PERSONAL CARE HOME LLC
Entity type:Organization
Organization Name:LIVING WELL PERSONAL CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGENETTE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:AGAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-829-3499
Mailing Address - Street 1:10903 WHEELER TRCE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6461
Mailing Address - Country:US
Mailing Address - Phone:678-829-3499
Mailing Address - Fax:678-829-3499
Practice Address - Street 1:10903 WHEELER TRCE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6461
Practice Address - Country:US
Practice Address - Phone:678-829-3499
Practice Address - Fax:678-829-3499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities