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General NPI Number Information
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NPI Number | 1760204697
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Entity Type | Organization
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Legal Business Name | LIVELY RESIDENTIAL PARADISE
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Dates
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Enumeration Date | 10/30/2024
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 16558 MANSFIELD ST
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City | DETROIT
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State | MI
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Zip | 48235-3631
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Country | US
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Telephone | 313-229-6215
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Fax |
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Provider Business Mailing Address
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Address Line | 25900 GREENFIELD RD STE 350
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City | OAK PARK
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State | MI
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Zip | 48237-1297
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Country | US
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Telephone | 313-229-6215
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Fax | 404-900-3987
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Authorized Official
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Title or Position | OWNER
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Name | SANTANNA LIVELY
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Credential |
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Telephone | 313-340-2225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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