Healthcare Provider Details

I. General information

NPI: 1629915962
Provider Name (Legal Business Name): LIFE LINE TECHNOLOGIES, INC DBA XSTREMEMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 FORUM DR
BROUSSARD LA
70518-8060
US

IV. Provider business mailing address

1028 FORUM DR
BROUSSARD LA
70518-8060
US

V. Phone/Fax

Practice location:
  • Phone: 337-704-0891
  • Fax: 337-704-2974
Mailing address:
  • Phone: 337-704-0891
  • Fax: 337-704-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL LYLE ODINET
Title or Position: CMO
Credential: MD
Phone: 337-704-0981