Provider Demographics
NPI:1073660825
Name:LIFELINE PARTNERS OF CANTON, INC
Entity Type:Organization
Organization Name:LIFELINE PARTNERS OF CANTON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGDORF
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:330-759-9233
Mailing Address - Street 1:6520 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7340
Mailing Address - Country:US
Mailing Address - Phone:330-494-7297
Mailing Address - Fax:330-494-7365
Practice Address - Street 1:6520 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7340
Practice Address - Country:US
Practice Address - Phone:330-494-7297
Practice Address - Fax:330-494-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH364518Medicare Oscar/Certification