Provider Demographics
NPI:1811548381
Name:LIFELINE HEALTH CARE LLC
Entity Type:Organization
Organization Name:LIFELINE HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MSN,APRN,CNP
Authorized Official - Phone:405-747-4835
Mailing Address - Street 1:704 AZALEA HILL DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6504
Mailing Address - Country:US
Mailing Address - Phone:405-747-4835
Mailing Address - Fax:405-467-4417
Practice Address - Street 1:704 AZALEA HILL DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6504
Practice Address - Country:US
Practice Address - Phone:405-747-4835
Practice Address - Fax:405-467-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK14549721OtherCAQH