MEDICARE: LIFELINE BIOSCIENCES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14D2252343	OTHER	IL	CLIA

General Provider Information

NPI Number	:	1962158980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE BIOSCIENCES LLC

Provider Business Mailing Address
First Line	:	2777 FINLEY RD STE 19
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1053
Country	:	US
Telephone Number	:	331-356-4264
Fax Number	:

Provider Business Practice Location Address
First Line	:	2777 FINLEY RD STE 19
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1053
Country	:	US
Telephone Number	:	331-356-4264
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NADEEM KHAN
Credential	:
Telephone Number	:	331-356-4264

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	11/29/2023

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