Healthcare Provider Details

I. General information

NPI: 1811006638
Provider Name (Legal Business Name): LIFELINE HEALTH CARE OF SOUTH FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13365 OVERSEAS HWY STE 104
MARATHON FL
33050-3513
US

IV. Provider business mailing address

600 CLIFTY ST
SOMERSET KY
42503-1733
US

V. Phone/Fax

Practice location:
  • Phone: 305-743-9817
  • Fax: 305-743-9873
Mailing address:
  • Phone: 606-679-4100
  • Fax: 606-678-7306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number21872096
License Number StateFL

VIII. Authorized Official

Name: MR. JAMES T. WILSON
Title or Position: CEO
Credential:
Phone: 606-679-4100