1083950356 NPI number — LIFELINE PENSACOLA, LLC

Table of content: (NPI 1083950356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083950356 NPI number — LIFELINE PENSACOLA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELINE PENSACOLA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COASTAL VASCULAR & INTERVENTIONAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083950356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 782412
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-2412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-388-2001
Provider Business Mailing Address Fax Number:
847-388-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1851 N 9TH AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-912-8843
Provider Business Practice Location Address Fax Number:
850-432-0802
Provider Enumeration Date:
12/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LOHMEYER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
847-949-3855

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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