Provider Demographics
NPI:1083950356
Name:LIFELINE PENSACOLA, LLC
Entity Type:Organization
Organization Name:LIFELINE PENSACOLA, LLC
Other - Org Name:COASTAL VASCULAR & INTERVENTIONAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOHMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-949-3855
Mailing Address - Street 1:PO BOX 782412
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-2412
Mailing Address - Country:US
Mailing Address - Phone:847-388-2001
Mailing Address - Fax:847-388-2020
Practice Address - Street 1:1851 N 9TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-5201
Practice Address - Country:US
Practice Address - Phone:850-912-8843
Practice Address - Fax:850-432-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty