Provider Demographics
NPI:1699516534
Name:LIVING WATER RESIDENTIAL SERVICES
Entity type:Organization
Organization Name:LIVING WATER RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN. CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LASHUNTA
Authorized Official - Middle Name:SHARLAN
Authorized Official - Last Name:PRINGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-278-5964
Mailing Address - Street 1:PO BOX 7563
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-7563
Mailing Address - Country:US
Mailing Address - Phone:318-278-5964
Mailing Address - Fax:318-343-7125
Practice Address - Street 1:4201 SPURGEON DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-4521
Practice Address - Country:US
Practice Address - Phone:318-614-7644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children