Provider Demographics
NPI:1760480743
Name:JRSP CORPORATION
Entity Type:Organization
Organization Name:JRSP CORPORATION
Other - Org Name:LIFELINE MEDICAL & DIABETIC SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MICHEAL
Authorized Official - Last Name:PUSCIZNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-646-6400
Mailing Address - Street 1:122 HAILES HILL RD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-3604
Mailing Address - Country:US
Mailing Address - Phone:508-646-6400
Mailing Address - Fax:
Practice Address - Street 1:1211 GAR HWY
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4225
Practice Address - Country:US
Practice Address - Phone:508-646-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1092840001332B00000X, 335E00000X
MA389254332B00000X
MA1538586332B00000X
MA3369333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA389254OtherBCBS OF MASS PROVIDER #
MA3369OtherMASS PHARMACY LIC#
MA1538586Medicaid
MA1538586Medicaid