Provider Demographics
NPI:1528026226
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:DR
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:229-382-1334
Mailing Address - Fax:229-382-1350
Practice Address - Street 1:1610 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3756
Practice Address - Country:US
Practice Address - Phone:229-382-1334
Practice Address - Fax:229-382-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE007390332B00000X, 332BP3500X, 332BX2000X, 3336C0004X, 332B00000X
FL1370332B00000X, 332BP3500X
FL322562332BX2000X
FLPH18569333600000X, 3336C0004X, 3336H0001X, 3336S0011X, 3336H0001X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00494337BMedicaid
GA00494337AMedicaid
GA1148243OtherNABP
0942290001Medicare ID - Type Unspecified