Provider Demographics
NPI:1184892648
Name:LIFECARE MEDICAL, INC.
Entity type:Organization
Organization Name:LIFECARE MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-764-0976
Mailing Address - Street 1:PO BOX 11770
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0031
Mailing Address - Country:US
Mailing Address - Phone:501-764-0976
Mailing Address - Fax:501-764-0990
Practice Address - Street 1:707 PARKWAY ST
Practice Address - Street 2:STE. 101
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-5340
Practice Address - Country:US
Practice Address - Phone:501-764-0976
Practice Address - Fax:501-764-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167958716Medicaid
IL=========001Medicaid
AR167958716Medicaid