1619079019 NPI number — LIFELINE HEALTH CARE OF NORTH FLORIDA, INC.

Table of content: (NPI 1619079019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619079019 NPI number — LIFELINE HEALTH CARE OF NORTH FLORIDA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELINE HEALTH CARE OF NORTH FLORIDA, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619079019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 CLIFTY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42503-1733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-679-4100
Provider Business Mailing Address Fax Number:
606-678-7306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 US HWY 441 NORTH
Provider Second Line Business Practice Location Address:
SUITE 1108
Provider Business Practice Location Address City Name:
THE VILLAGES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-753-4631
Provider Business Practice Location Address Fax Number:
352-753-7580
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
606-679-4100

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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