=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730868498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2023
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11456 MEADOWBROOK DR
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-6554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-739-7805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11456 MEADOWBROOK DR
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-6554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAWN GOBLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-739-7805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------