Provider Demographics
NPI:1932104817
Name:LIFELINE PRIVATE DUTY HOME HEALTH CARE, INC.
Entity Type:Organization
Organization Name:LIFELINE PRIVATE DUTY HOME HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JEANIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:405-224-4891
Mailing Address - Street 1:PO BOX 1348
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-1348
Mailing Address - Country:US
Mailing Address - Phone:405-224-4891
Mailing Address - Fax:405-224-4895
Practice Address - Street 1:917 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-4655
Practice Address - Country:US
Practice Address - Phone:405-224-4891
Practice Address - Fax:405-224-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7471251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID NUMBER