Provider Demographics
NPI:1144734252
Name:LIVING WELL AT HOME
Entity type:Organization
Organization Name:LIVING WELL AT HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN CLINICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANELL
Authorized Official - Middle Name:LOVETTE
Authorized Official - Last Name:WOODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:713-665-9952
Mailing Address - Street 1:PO BOX 2177
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-0177
Mailing Address - Country:US
Mailing Address - Phone:631-591-0298
Mailing Address - Fax:
Practice Address - Street 1:103 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:FLANDERS
Practice Address - State:NY
Practice Address - Zip Code:11901-3850
Practice Address - Country:US
Practice Address - Phone:631-591-0298
Practice Address - Fax:631-740-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163WH0200X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1902324502Medicaid