Provider Demographics
NPI:1952507378
Name:LIVIRAE LINGERIE, LLC
Entity Type:Organization
Organization Name:LIVIRAE LINGERIE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASTECTOMY FIT ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-429-7004
Mailing Address - Street 1:2975 RING RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4912
Mailing Address - Country:US
Mailing Address - Phone:770-429-7004
Mailing Address - Fax:770-429-7069
Practice Address - Street 1:2975 RING RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4912
Practice Address - Country:US
Practice Address - Phone:770-429-7004
Practice Address - Fax:770-429-7069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier