Provider Demographics
NPI:1265776017
Name:LIVING WATER WELLNESS AND THERAPY LLC
Entity type:Organization
Organization Name:LIVING WATER WELLNESS AND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ARIAN
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, DMT
Authorized Official - Phone:248-210-8805
Mailing Address - Street 1:7895 BROADWAY STE D
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5529
Mailing Address - Country:US
Mailing Address - Phone:213-200-2163
Mailing Address - Fax:
Practice Address - Street 1:6643 LAGOON WAY
Practice Address - Street 2:APARTMENT 4
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4277
Practice Address - Country:US
Practice Address - Phone:248-210-8805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-17
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
IN05010477A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty