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General NPI Number Information
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NPI Number | 1497761886
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Entity Type | Organization
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Legal Business Name | LIFELINE MOBILE MEDICS
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Dates
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Enumeration Date | 07/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 112 SOUTHGATE DR #B
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City | BLOOMINGTON
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State | IL
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Zip | 61704-7639
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Country | US
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Telephone | 309-828-8572
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Fax | 309-827-3060
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Provider Business Mailing Address
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Address Line | 112 SOUTHGATE DR #B
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City | BLOOMINGTON
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State | IL
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Zip | 61704-7639
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Country | US
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Telephone | 309-828-8572
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Fax | 309-827-3060
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Authorized Official
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Title or Position | CEO
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Name | KEITH RICHARD DUTTON
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Credential |
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Telephone | 309-828-8572
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 341600000X
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Taxonomy Name | Ambulance
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License Number |
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License Number State | IL
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