Provider Demographics
NPI:1710134580
Name:DR. LIVELY'S CHILD & FAMILY WELLNESS CTR. PC
Entity Type:Organization
Organization Name:DR. LIVELY'S CHILD & FAMILY WELLNESS CTR. PC
Other - Org Name:DR. K. FOR KIDS, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-225-3137
Mailing Address - Street 1:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-0990
Mailing Address - Country:US
Mailing Address - Phone:918-225-3137
Mailing Address - Fax:918-355-0298
Practice Address - Street 1:5505 EW 75TH RD
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-5555
Practice Address - Country:US
Practice Address - Phone:918-225-3137
Practice Address - Fax:918-355-0298
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. K.FOR KIDS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK766302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization