Provider Demographics
NPI:1720140239
Name:LIFE GUARD INC
Entity Type:Organization
Organization Name:LIFE GUARD INC
Other - Org Name:WYOMING HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-665-2346
Mailing Address - Street 1:CORNER OF BANK & MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874
Mailing Address - Country:US
Mailing Address - Phone:304-732-9270
Mailing Address - Fax:304-732-9270
Practice Address - Street 1:CORNER OF BANK & MAIN ST.
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874
Practice Address - Country:US
Practice Address - Phone:304-732-9270
Practice Address - Fax:304-732-9270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE REQUIRED332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6204088000Medicaid
WV6204088000Medicaid