Living Waters Community Medical Center PLLC

Primary specialty

SpecialistTaxonomy code 174400000X

License

06960 Issued in MS

Legal business name

LIVING WATERS COMMUNITY MEDICAL CENTER PLLC

Practice address

13472 Vidalia Rd
Pass Christian, MS 39571-8300

Phone

(228) 586-2455

NPI assigned

Dec 12, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Lisa Marie Tillman

Title

Office Manager

Phone

(228) 586-2455

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1197417600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1197417600000",
    "number": "1144403122",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13472 VIDALIA RD",
            "city": "PASS CHRISTIAN",
            "state": "MS",
            "postal_code": "395718300",
            "telephone_number": "228-586-2455"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13472 VIDALIA RD",
            "city": "PASS CHRISTIAN",
            "state": "MS",
            "postal_code": "395718300",
            "telephone_number": "228-586-2455"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIVING WATERS COMMUNITY MEDICAL CENTER PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-12",
        "last_updated": "2007-12-12",
        "status": "A",
        "authorized_official_last_name": "TILLMAN",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "228-586-2455",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "MS",
            "license": "06960",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015234",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Pass Christian, MS
• Specialist in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.