1962849794 NPI number — LIFELINE VASCULAR CENTER NICEVILLE LLC

Table of content: CHERYL ANN BECKER CNP (NPI 1518469295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962849794 NPI number — LIFELINE VASCULAR CENTER NICEVILLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELINE VASCULAR CENTER NICEVILLE LLC
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:
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:
1962849794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 782282
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-388-2001
Provider Business Mailing Address Fax Number:
847-388-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4585 E HIGHWAY 20 STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-7709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-678-0184
Provider Business Practice Location Address Fax Number:
850-678-0155
Provider Enumeration Date:
06/03/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOHMEYER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
847-949-3855

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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