Provider Demographics
NPI:1497761886
Name:LIFELINE MOBILE MEDICS
Entity Type:Organization
Organization Name:LIFELINE MOBILE MEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-8572
Mailing Address - Street 1:112 SOUTHGATE DR
Mailing Address - Street 2:#B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7639
Mailing Address - Country:US
Mailing Address - Phone:309-828-8572
Mailing Address - Fax:309-827-3060
Practice Address - Street 1:112 SOUTHGATE DR
Practice Address - Street 2:#B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7639
Practice Address - Country:US
Practice Address - Phone:309-828-8572
Practice Address - Fax:309-827-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid