Provider Demographics
NPI:1689671836
Name:LIFE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:LIFE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DORCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-566-1674
Mailing Address - Street 1:PO BOX 550309
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-0309
Mailing Address - Country:US
Mailing Address - Phone:205-566-1674
Mailing Address - Fax:205-278-6900
Practice Address - Street 1:224 N MCCOLL RD STE A
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-9310
Practice Address - Country:US
Practice Address - Phone:956-994-3600
Practice Address - Fax:956-994-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0079549A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172219102Medicaid