Provider Demographics
NPI:1972152908
Name:LIVING LIFE
Entity type:Organization
Organization Name:LIVING LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-696-1806
Mailing Address - Street 1:7305 HANCOCK VILLAGE DR
Mailing Address - Street 2:PO BOX 124
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-1369
Mailing Address - Country:US
Mailing Address - Phone:804-307-4589
Mailing Address - Fax:
Practice Address - Street 1:595 SOUTHLAKE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-4942
Practice Address - Country:US
Practice Address - Phone:757-696-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Multi-Specialty