Healthcare Provider Details

I. General information

NPI: 1154678852
Provider Name (Legal Business Name): LIFE LINE HEALTH PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 SAINT JOHNS BLUFF RD S SUITE 3
JACKSONVILLE FL
32224-2651
US

IV. Provider business mailing address

3740 SAINT JOHNS BLUFF RD S SUITE 3
JACKSONVILLE FL
32224-2651
US

V. Phone/Fax

Practice location:
  • Phone: 904-730-2223
  • Fax: 904-730-2231
Mailing address:
  • Phone: 904-730-2223
  • Fax: 904-730-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RONNIE C DANIEL
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 904-730-2223