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General NPI Number Information
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NPI Number | 1962849794
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Entity Type | Organization
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Legal Business Name | LIFELINE VASCULAR CENTER NICEVILLE LLC
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 06/30/2021
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Provider Practice Location Address
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Address Line | 4585 E HIGHWAY 20 STE 125
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City | NICEVILLE
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State | FL
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Zip | 32578-7709
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Country | US
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Telephone | 850-678-0184
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Fax | 850-678-0155
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Provider Business Mailing Address
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Address Line | PO BOX 782282
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City | PHILADELPHIA
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State | PA
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Zip | 19178-2282
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Country | US
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Telephone | 847-388-2001
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Fax | 847-388-2020
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Authorized Official
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Title or Position | CFO
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Name | JASON LOHMEYER
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Credential |
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Telephone | 847-949-3855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology 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 | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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