Provider Demographics
NPI:1649204421
Name:LIFELINE HOME HEALTH CARE OF RUSSELLVILLE, LLC
Entity Type:Organization
Organization Name:LIFELINE HOME HEALTH CARE OF RUSSELLVILLE, LLC
Other - Org Name:LIFELINE HEALTH CARE OF LOGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:STELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:1527 NASHVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8851
Practice Address - Country:US
Practice Address - Phone:270-726-2408
Practice Address - Fax:270-726-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100003520Medicaid
KY000000503509OtherANTHEM BLUE CROSS BLUE SH
KY7100003530Medicaid
KY7100005720Medicaid
KY7100003530Medicaid