Provider Demographics
NPI:1770973794
Name:LIVE LONG AND HEALTHYLLC
Entity type:Organization
Organization Name:LIVE LONG AND HEALTHYLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:APRIL LATOCK
Authorized Official - Last Name:MIKEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:410-215-4145
Mailing Address - Street 1:1117 E NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1930
Mailing Address - Country:US
Mailing Address - Phone:410-215-4145
Mailing Address - Fax:
Practice Address - Street 1:1117 E NORTHERN PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1930
Practice Address - Country:US
Practice Address - Phone:410-215-4145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management