Provider Demographics
NPI:1760204697
Name:LIVELY RESIDENTIAL PARADISE
Entity type:Organization
Organization Name:LIVELY RESIDENTIAL PARADISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANTANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-340-2225
Mailing Address - Street 1:25900 GREENFIELD RD STE 350
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1297
Mailing Address - Country:US
Mailing Address - Phone:313-229-6215
Mailing Address - Fax:404-900-3987
Practice Address - Street 1:16558 MANSFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3631
Practice Address - Country:US
Practice Address - Phone:313-229-6215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities