Basic Information
| Provider Information | |||||||||
| NPI: | 1194295980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVING WATER FAMILY SERVICES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 645 HIGHWAY 80 E | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712038527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183438744 | ||||||||
| FaxNumber: | 3183457123 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 HIGHWAY 80 E | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712038527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183438744 | ||||||||
| FaxNumber: | 3183457123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2018 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | ADRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3186147644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.