Provider Demographics
NPI:1376286674
Name:LIVELYCARE
Entity Type:Organization
Organization Name:LIVELYCARE
Other - Org Name:OWNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:ARDELLA
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-683-3025
Mailing Address - Street 1:4401 FLOWERTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1510
Mailing Address - Country:US
Mailing Address - Phone:443-683-3025
Mailing Address - Fax:
Practice Address - Street 1:4401 FLOWERTON RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1510
Practice Address - Country:US
Practice Address - Phone:443-683-3025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT082720220000017Medicaid