Provider Demographics
NPI:1710403118
Name:LIV-ON FAMILY CARE CENTER, PA
Entity Type:Organization
Organization Name:LIV-ON FAMILY CARE CENTER, PA
Other - Org Name:LIV-ON FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-FNP-BC
Authorized Official - Phone:651-666-0915
Mailing Address - Street 1:5 COUNTY ROAD B E STE 3
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1945
Mailing Address - Country:US
Mailing Address - Phone:651-207-8372
Mailing Address - Fax:651-379-4727
Practice Address - Street 1:5 COUNTY ROAD B E STE 3
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-1945
Practice Address - Country:US
Practice Address - Phone:651-207-8372
Practice Address - Fax:651-379-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2014035499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1457746281Medicaid