Healthcare Provider Details

I. General information

NPI: 1083950356
Provider Name (Legal Business Name): LIFELINE PENSACOLA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 N 9TH AVE STE B
PENSACOLA FL
32503-5201
US

IV. Provider business mailing address

PO BOX 782412
PHILADELPHIA PA
19178-2412
US

V. Phone/Fax

Practice location:
  • Phone: 850-912-8843
  • Fax: 850-432-0802
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