Provider Demographics
NPI:1114081619
Name:LIFECARE HOME NURSING, LLC
Entity Type:Organization
Organization Name:LIFECARE HOME NURSING, LLC
Other - Org Name:LIFECARE RESPIRATORY & MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR / CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-297-9300
Mailing Address - Street 1:1905 NE STALLINGS DR STE 5
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-3805
Mailing Address - Country:US
Mailing Address - Phone:936-560-3500
Mailing Address - Fax:936-560-3505
Practice Address - Street 1:2618 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-3501
Practice Address - Country:US
Practice Address - Phone:936-560-3500
Practice Address - Fax:936-560-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0068227332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162528703Medicaid