Provider Demographics
NPI:1962849794
Name:LIFELINE VASCULAR CENTER NICEVILLE LLC
Entity Type:Organization
Organization Name:LIFELINE VASCULAR CENTER NICEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOHMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-949-3855
Mailing Address - Street 1:PO BOX 782282
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-2282
Mailing Address - Country:US
Mailing Address - Phone:847-388-2001
Mailing Address - Fax:847-388-2020
Practice Address - Street 1:4585 E HIGHWAY 20 STE 125
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-7709
Practice Address - Country:US
Practice Address - Phone:850-678-0184
Practice Address - Fax:850-678-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty