Provider Demographics
NPI:1407923022
Name:LIFE LINE HOME CARE INC
Entity Type:Organization
Organization Name:LIFE LINE HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-382-1334
Mailing Address - Street 1:1610 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3756
Mailing Address - Country:US
Mailing Address - Phone:904-321-0242
Mailing Address - Fax:904-321-0930
Practice Address - Street 1:220 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3216
Practice Address - Country:US
Practice Address - Phone:904-321-0242
Practice Address - Fax:904-321-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL55-8013641105-5332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0942290004OtherMEDICARE