Healthcare Provider Details

I. General information

NPI: 1700594355
Provider Name (Legal Business Name): MP LIVING CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 SEVENTH ST
AUBURN ME
04210-6626
US

IV. Provider business mailing address

227 SEVENTH ST
AUBURN ME
04210-6626
US

V. Phone/Fax

Practice location:
  • Phone: 347-740-5264
  • Fax:
Mailing address:
  • Phone: 347-740-5264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JOHNNY TSHIKULA ILUNGA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 134-774-0526