=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104295187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE INCOPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2015
-----------------------------------------------------
Last Update Date | 09/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6823D RIVERDALE RD APT D1
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20737-1835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-898-7756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6823D RIVERDALE RD APT D1
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20737-1835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HHA
-----------------------------------------------------
Name | NICHEU SHIENJI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-776-8456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------