Basic Information
| Provider Information | |||||||||
| NPI: | 1861733784 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSSCO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIVE WELL MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 JOHNSTON ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123521234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 JOHNSTON ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123521234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2013 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | HAROLD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123521234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 055437 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.