Provider Demographics
NPI:1942319744
Name:LIFELINE HEALTH CARE OF SOUTHWEST FLORIDA, INC.
Entity Type:Organization
Organization Name:LIFELINE HEALTH CARE OF SOUTHWEST FLORIDA, INC.
Other - Org Name:LIFELINE HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-4100
Mailing Address - Street 1:600 CLIFTY ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1733
Mailing Address - Country:US
Mailing Address - Phone:606-679-4100
Mailing Address - Fax:606-678-7306
Practice Address - Street 1:630A WOODBURY DR
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-1000
Practice Address - Country:US
Practice Address - Phone:941-766-9544
Practice Address - Fax:941-766-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20649096251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-7252Medicare ID - Type UnspecifiedHOME HEALTH