1215153432 NPI number — LIVING WATERS COORDINATED COMMUNITIES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215153432 NPI number — LIVING WATERS COORDINATED COMMUNITIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING WATERS COORDINATED COMMUNITIES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAIN MANAGEMENT PSYCHOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215153432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 W IRONWOOD DR
Provider Second Line Business Mailing Address:
SUITE D311
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-1403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-676-0926
Provider Business Mailing Address Fax Number:
208-676-0926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2108 N IRONWOOD CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-676-0926
Provider Business Practice Location Address Fax Number:
208-676-0926
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILHELM
Authorized Official First Name:
LAVERL
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT, PSYCHOLOGIST
Authorized Official Telephone Number:
208-676-0926

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  PSYCHOLOGY 202060 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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