Provider Demographics
NPI:1700460250
Name:LIVING WELL COLLECTIVE CO
Entity Type:Organization
Organization Name:LIVING WELL COLLECTIVE CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-339-5937
Mailing Address - Street 1:12400 YELLOW BLUFF RD STE 107
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5070
Mailing Address - Country:US
Mailing Address - Phone:904-339-5937
Mailing Address - Fax:904-615-6978
Practice Address - Street 1:12400 YELLOW BLUFF RD STE 107
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-5070
Practice Address - Country:US
Practice Address - Phone:904-339-5937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service