Provider Demographics
NPI:1881757938
Name:LIVING WATER COMMUNITY DEVELOPMENT CORPORATION, INC
Entity type:Organization
Organization Name:LIVING WATER COMMUNITY DEVELOPMENT CORPORATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LENOR
Authorized Official - Last Name:GOODING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-822-3004
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-0267
Mailing Address - Country:US
Mailing Address - Phone:704-822-3004
Mailing Address - Fax:704-827-6031
Practice Address - Street 1:3906 HICKORY GROVE RD
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-9618
Practice Address - Country:US
Practice Address - Phone:704-822-3004
Practice Address - Fax:704-827-6031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8700401Medicaid