Healthcare Provider Details

I. General information

NPI: 1396001665
Provider Name (Legal Business Name): LIFENET, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18098 E 54 HWY
NEVADA MO
64772-8012
US

IV. Provider business mailing address

621 CARNEGIE DR SUITE 210
SAN BERNARDINO CA
92408-3536
US

V. Phone/Fax

Practice location:
  • Phone: 800-636-4438
  • Fax:
Mailing address:
  • Phone: 800-636-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number510092
License Number StateMO

VIII. Authorized Official

Name: MARK RAYMOND KEENE
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 909-915-2301