=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730249376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE GUARD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 07/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 299 1/2 NORTH STATE ROUTE 2
-----------------------------------------------------
City | NEW MARTINSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-455-0250
-----------------------------------------------------
Fax | 304-455-0250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 299 1/2 NORTH STATE ROUTE 2
-----------------------------------------------------
City | NEW MARTINSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-455-0250
-----------------------------------------------------
Fax | 304-455-0250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | V.P.
-----------------------------------------------------
Name | MATT SHIVELY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-665-2346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | NONE REQUIRED
-----------------------------------------------------
License Number State |
-----------------------------------------------------