Provider Demographics
NPI:1124568571
Name:LIFELINE HEALTH ESSENTIALS LLC
Entity Type:Organization
Organization Name:LIFELINE HEALTH ESSENTIALS LLC
Other - Org Name:THE MASTECTOMY BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:IISHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:504-758-4220
Mailing Address - Street 1:PO BOX 2864
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70059-2864
Mailing Address - Country:US
Mailing Address - Phone:504-758-4220
Mailing Address - Fax:
Practice Address - Street 1:4700 WICHERS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3041
Practice Address - Country:US
Practice Address - Phone:504-758-4220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 335E00000X
LA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No335E00000XSuppliersProsthetic/Orthotic Supplier