Provider Demographics
NPI:1821028044
Name:LIFECARE MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:LIFECARE MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-792-0754
Mailing Address - Street 1:4506 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3027
Mailing Address - Country:US
Mailing Address - Phone:903-792-0754
Mailing Address - Fax:903-792-0756
Practice Address - Street 1:4506 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3027
Practice Address - Country:US
Practice Address - Phone:903-792-0754
Practice Address - Fax:903-792-0756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5559910002Medicare NSC