Healthcare Provider Details

I. General information

NPI: 1679162549
Provider Name (Legal Business Name): KIMBERLY LIVELY BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

IV. Provider business mailing address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-9541
  • Fax: 951-944-0592
Mailing address:
  • Phone: 304-732-6043
  • Fax: 951-944-0592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: