Provider Demographics
NPI:1598098873
Name:LIFELINE PEDIATRIC CLINICS
Entity Type:Organization
Organization Name:LIFELINE PEDIATRIC CLINICS
Other - Org Name:LIFESTEPS PEDIATRIC THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GALLO
Authorized Official - Suffix:
Authorized Official - Credentials:RNC, WHNP B-C, CST
Authorized Official - Phone:940-367-3501
Mailing Address - Street 1:3501 SHEPPARD ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76306-4235
Mailing Address - Country:US
Mailing Address - Phone:940-851-7837
Mailing Address - Fax:
Practice Address - Street 1:3501 SHEPPARD ACCESS RD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76306-4235
Practice Address - Country:US
Practice Address - Phone:940-851-7837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX666670000261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy