Healthcare Provider Details

I. General information

NPI: 1538531058
Provider Name (Legal Business Name): TIMOTHY LIVELY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 NORTHWOODS DR STE 240
ARDEN HILLS MN
55112-6991
US

IV. Provider business mailing address

3900 NORTHWOODS DR STE 240
ARDEN HILLS MN
55112-6991
US

V. Phone/Fax

Practice location:
  • Phone: 651-633-7300
  • Fax: 651-633-7301
Mailing address:
  • Phone: 651-633-7300
  • Fax: 651-633-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number370453
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: