Provider Demographics
NPI:1669171369
Name:LIVING WELL PEDIATRICS, PC
Entity type:Organization
Organization Name:LIVING WELL PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:816-200-4491
Mailing Address - Street 1:370 OAKHURST VISTA
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376
Mailing Address - Country:US
Mailing Address - Phone:816-200-4491
Mailing Address - Fax:910-240-9469
Practice Address - Street 1:289 OLMSTED BLVD
Practice Address - Street 2:UNIT 3, STE 5
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8730
Practice Address - Country:US
Practice Address - Phone:910-541-5880
Practice Address - Fax:910-240-9469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty