Provider Demographics
NPI:1922385194
Name:LIFELINE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:LIFELINE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAKA
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:EROJE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-702-7518
Mailing Address - Street 1:1802 ROCKAWAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5006
Mailing Address - Country:US
Mailing Address - Phone:646-702-7518
Mailing Address - Fax:
Practice Address - Street 1:1802 ROCKAWAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5006
Practice Address - Country:US
Practice Address - Phone:646-702-7518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies