Provider Demographics
NPI:1255586111
Name:LIFE GUARD INC.
Entity type:Organization
Organization Name:LIFE GUARD INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-665-2346
Mailing Address - Street 1:208 RIVERVIEW DR.
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26134
Mailing Address - Country:US
Mailing Address - Phone:304-665-2346
Mailing Address - Fax:304-665-9402
Practice Address - Street 1:105 DUNCAN ROAD
Practice Address - Street 2:
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954
Practice Address - Country:US
Practice Address - Phone:304-665-2346
Practice Address - Fax:304-665-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014683Medicaid
WV3810014683Medicaid