=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083619969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE HOSPICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 S 16TH ST
-----------------------------------------------------
City | CHICKASHA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73018-6432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-222-2051
-----------------------------------------------------
Fax | 405-222-2151
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1348
-----------------------------------------------------
City | CHICKASHA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73023-1348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-222-2051
-----------------------------------------------------
Fax | 405-222-2151
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. KELLY D JEANIS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 405-224-4891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 4150
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------