MEDICARE: PHILADELPHIA LIVES MATTER 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	253Z00000X	In Home Supportive Care Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144807538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILADELPHIA LIVES MATTER LLC

Provider Business Mailing Address
First Line	:	8500 LINDBERGH BLVD APT 1807
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-1521
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8500 LINDBERGH BLVD APT 1807
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-1521
Country	:	US
Telephone Number	:	267-265-4670
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	STANLEY WILLIAMS
Credential	:
Telephone Number	:	267-265-4670

Provider Enumeration Date	:	03/24/2021
Last Update Date	:	03/24/2021

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