Provider Demographics
NPI:1861963050
Name:LIVING HEALTHY WELLNESS CENTER
Entity type:Organization
Organization Name:LIVING HEALTHY WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP-BC
Authorized Official - Phone:615-454-2016
Mailing Address - Street 1:414 W OLD HICKORY BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-3653
Mailing Address - Country:US
Mailing Address - Phone:615-454-2016
Mailing Address - Fax:615-454-2507
Practice Address - Street 1:414 W OLD HICKORY BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-3653
Practice Address - Country:US
Practice Address - Phone:615-456-2016
Practice Address - Fax:615-454-2507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044948Medicaid