Healthcare Provider Details

I. General information

NPI: 1962849794
Provider Name (Legal Business Name): LIFELINE VASCULAR CENTER NICEVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4585 E HIGHWAY 20 STE 125
NICEVILLE FL
32578-7709
US

IV. Provider business mailing address

PO BOX 782282
PHILADELPHIA PA
19178-2282
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-0184
  • Fax: 850-678-0155
Mailing address:
  • Phone: 847-388-2001
  • Fax: 847-388-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON LOHMEYER
Title or Position: CFO
Credential:
Phone: 847-949-3855