MEDICARE: LILY CARE HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1134924939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LILY CARE HOME LLC

Provider Business Mailing Address
First Line	:	432 SPRING AIR DR
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002-5318
Country	:	US
Telephone Number	:	206-353-6507
Fax Number	:

Provider Business Practice Location Address
First Line	:	432 SPRING AIR DR
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002-5318
Country	:	US
Telephone Number	:	206-353-6507
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	ELELITA WOLDEMICHAEL
Credential	:
Telephone Number	:	206-353-6507

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	02/20/2025

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Directions to “LILY CARE HOME LLC ” Practice Location

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