Provider Demographics
NPI:1447395470
Name:LIFESTAT OF NEO CO
Entity Type:Organization
Organization Name:LIFESTAT OF NEO CO
Other - Org Name:LIFELINE EMS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-258-6579
Mailing Address - Street 1:102 N ELM PL
Mailing Address - Street 2:SUITE G
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3883
Mailing Address - Country:US
Mailing Address - Phone:918-258-6579
Mailing Address - Fax:918-258-6500
Practice Address - Street 1:102 N ELM PL
Practice Address - Street 2:SUITE G
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3883
Practice Address - Country:US
Practice Address - Phone:918-258-6579
Practice Address - Fax:918-258-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3873416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS OF OKLAHOMA