Provider Demographics
NPI:1518027150
Name:LIFE GUARD INC
Entity Type:Organization
Organization Name:LIFE GUARD INC
Other - Org Name:LIFE GUARD MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-665-2346
Mailing Address - Street 1:71 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MC CONNELSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43756-1180
Mailing Address - Country:US
Mailing Address - Phone:740-962-5223
Mailing Address - Fax:740-962-5223
Practice Address - Street 1:71 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MC CONNELSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43756-1180
Practice Address - Country:US
Practice Address - Phone:740-962-5223
Practice Address - Fax:740-962-5223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHMEL 11133332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2412268Medicaid
OH2412268Medicaid