Provider Demographics
NPI:1740283217
Name:LIFE LINE MEDICAL SUPPLY CO.
Entity type:Organization
Organization Name:LIFE LINE MEDICAL SUPPLY CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-522-4351
Mailing Address - Street 1:4424 VANDELIA ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2047
Mailing Address - Country:US
Mailing Address - Phone:214-522-4351
Mailing Address - Fax:
Practice Address - Street 1:805 W PRICE RD
Practice Address - Street 2:STE C-1
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8745
Practice Address - Country:US
Practice Address - Phone:956-504-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4795460002Medicare NSC