Provider Demographics
NPI:1992738991
Name:LIVINGWATER'S MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:LIVINGWATER'S MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:YUJUNG
Authorized Official - Last Name:YUN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-694-8549
Mailing Address - Street 1:24910 LAS BRISAS RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4010
Mailing Address - Country:US
Mailing Address - Phone:951-694-8549
Mailing Address - Fax:951-220-8307
Practice Address - Street 1:24910 LAS BRISAS RD
Practice Address - Street 2:SUITE 111
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4010
Practice Address - Country:US
Practice Address - Phone:951-694-8549
Practice Address - Fax:951-220-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8759261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87590Medicaid
CAH78016Medicare UPIN
CA020A87591Medicare PIN
CAZZZ02419ZMedicare ID - Type UnspecifiedGROUP ID