Provider Demographics
NPI:1619112323
Name:LIFELINE
Entity Type:Organization
Organization Name:LIFELINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:MAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:BBA
Authorized Official - Phone:615-781-0013
Mailing Address - Street 1:599 VICKERS PL STE D
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4076
Mailing Address - Country:US
Mailing Address - Phone:931-525-6773
Mailing Address - Fax:
Practice Address - Street 1:599 VICKERS PL STE D
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4076
Practice Address - Country:US
Practice Address - Phone:931-525-6773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFECARE FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000003680251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376955OtherGROUP MEDICARE