Healthcare Provider Details

I. General information

NPI: 1083619969
Provider Name (Legal Business Name): LIFELINE HOSPICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 S 16TH ST
CHICKASHA OK
73018-6432
US

IV. Provider business mailing address

PO BOX 1348
CHICKASHA OK
73023-1348
US

V. Phone/Fax

Practice location:
  • Phone: 405-222-2051
  • Fax: 405-222-2151
Mailing address:
  • Phone: 405-222-2051
  • Fax: 405-222-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number4150
License Number StateOK

VIII. Authorized Official

Name: MS. KELLY D JEANIS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 405-224-4891