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General NPI Number Information
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NPI Number | 1174705859
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Entity Type | Organization
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Legal Business Name | LIFELINE EMS LLC
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 06/22/2011
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Provider Practice Location Address
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Address Line | 510 E JACKSON AVE
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City | WEST MEMPHIS
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State | AR
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Zip | 72301-4336
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Country | US
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Telephone | 870-735-9718
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Fax | 870-735-9718
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Provider Business Mailing Address
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Address Line | 510 E JACKSON AVE
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City | WEST MEMPHIS
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State | AR
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Zip | 72301-4336
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Country | US
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Telephone | 870-735-9718
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Fax | 870-735-9718
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHARLIE ANDREW TACITO
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Credential | EMT
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Telephone | 901-619-3127
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number | 0000010018
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License Number State | TN
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