Provider Demographics
NPI:1881761492
Name:LIFE LINE HOME CARE INC
Entity type:Organization
Organization Name:LIFE LINE HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-382-1334
Mailing Address - Street 1:1610 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3756
Mailing Address - Country:US
Mailing Address - Phone:912-673-8544
Mailing Address - Fax:912-673-8554
Practice Address - Street 1:100 LAKESHORE DR
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3857
Practice Address - Country:US
Practice Address - Phone:912-673-8544
Practice Address - Fax:912-673-8554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA303718793332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0942290005OtherMEDICARE