Provider Demographics
NPI:1922990548
Name:LIVEWELL PASSPORT OF FLORIDA LLC
Entity type:Organization
Organization Name:LIVEWELL PASSPORT OF FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:SOWERS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:804-614-8619
Mailing Address - Street 1:22606 PANAMA CITY BEACH PKWY
Mailing Address - Street 2:
Mailing Address - City:INLET BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-1150
Mailing Address - Country:US
Mailing Address - Phone:804-614-8619
Mailing Address - Fax:844-777-1754
Practice Address - Street 1:22606 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:INLET BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-1150
Practice Address - Country:US
Practice Address - Phone:804-614-8619
Practice Address - Fax:844-777-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-17
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care