Basic Information
| Provider Information | |||||||||
| NPI: | 1013371251 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVE LONG WELL CARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LIVE LONG WELL CARE OF MARSH'S EDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 TORINGDON WAY | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042461620 | ||||||||
| FaxNumber: | 7042461621 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 MARSHS EDGE LN | ||||||||
| Address2: | |||||||||
| City: | ST SIMONS ISLAND | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315228898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122912006 | ||||||||
| FaxNumber: | 9122912098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 04/13/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7042461620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.