=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679872907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFENET, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2011
-----------------------------------------------------
Last Update Date | 01/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10125 AIRPORT RD
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-636-4438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 CARNEGIE DR STE 210
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92408-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-636-4438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT
-----------------------------------------------------
Name | MARK RAYMOND KEENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-915-2301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416A0800X
-----------------------------------------------------
Taxonomy Name | Air Ambulance
-----------------------------------------------------
License Number | 97159
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------