| Living Waters Medical Center | |
|
100 Main Ave Logan WV 25601-3323 | |
| (304) 946-8350 | |
| Not Available |
| Full Name | Living Waters Medical Center |
|---|---|
| Speciality | Clinic/Center |
| Location | 100 Main Ave, Logan, West Virginia |
| Authorized Official Name and Position | Amber Ellis (DIRECTOR/FAMILY NURSE PRACTITIONER) |
| Authorized Official Contact | 3049468350 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Living Waters Medical Center 100 Main Ave Logan WV 25601-3323 Ph: () - | Living Waters Medical Center 100 Main Ave Logan WV 25601-3323 Ph: (304) 946-8350 |
| NPI Number | 1114585619 |
|---|---|
| Provider Enumeration Date | 05/31/2019 |
| Last Update Date | 03/26/2025 |
| Certification Date | 03/26/2025 |
| Medicare PECOS PAC ID | 2769711019 |
|---|---|
| Medicare Enrollment ID | O20190911002098 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114585619 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Secondary |
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Jon Robert Bowen |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1093929036 PECOS PAC ID: 5991871204 Enrollment ID: I20080911000192 |
| Provider Name | Amber M Ellis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1093049983 PECOS PAC ID: 7113068057 Enrollment ID: I20100114000031 |
| Provider Name | Philip A Galapon |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1033370051 PECOS PAC ID: 6507053675 Enrollment ID: I20101215000564 |
| Provider Name | Darlene M Fields |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164738530 PECOS PAC ID: 5294923306 Enrollment ID: I20101215001257 |
| Provider Name | Summer New |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1134643513 PECOS PAC ID: 6901163781 Enrollment ID: I20171204000896 |
| Provider Name | Lisa Perry |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841893146 PECOS PAC ID: 5799186524 Enrollment ID: I20210630001185 |
| Provider Name | Samantha Carter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1275212748 PECOS PAC ID: 7911343769 Enrollment ID: I20240314002910 |
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