Healthcare Provider Details

I. General information

NPI: 1477580959
Provider Name (Legal Business Name): LIFELINE OF FAIRFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 COLUMBIA RD
WINNSBORO SC
29180
US

IV. Provider business mailing address

P O DRAWER 60
WINNSBORO SC
29180-1732
US

V. Phone/Fax

Practice location:
  • Phone: 803-633-2107
  • Fax: 803-635-6147
Mailing address:
  • Phone: 803-633-2107
  • Fax: 803-635-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateSC

VIII. Authorized Official

Name: DEBBIE S. BROOM
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-633-2107