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General NPI Number Information
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NPI Number | 1306645577
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Entity Type | Organization
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Legal Business Name | LIFELINE TESTS INCORPORATED
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Dates
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Enumeration Date | 03/11/2025
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 296 ATLANTIC AVE STE A
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City | FREEPORT
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State | NY
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Zip | 11520-4243
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Country | US
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Telephone | 616-894-1615
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Fax |
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Provider Business Mailing Address
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Address Line | 296 ATLANTIC AVE STE A
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City | FREEPORT
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State | NY
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Zip | 11520-4243
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Country | US
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Telephone | 616-894-1615
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JACOB ROBERT PEACOCK
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Credential | MD
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Telephone | 616-894-1615
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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