Provider Demographics
NPI:1760635700
Name:LIFE STAR HEALTHCARE LLC
Entity Type:Organization
Organization Name:LIFE STAR HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-PARAMEDIC
Authorized Official - Phone:615-974-1632
Mailing Address - Street 1:111 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5101
Mailing Address - Country:US
Mailing Address - Phone:615-974-1632
Mailing Address - Fax:
Practice Address - Street 1:111 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5101
Practice Address - Country:US
Practice Address - Phone:615-974-1632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNEMT00000302523416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport