MEDICARE: LIFECARE HOME NURSING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0068227	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114081619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFECARE HOME NURSING, LLC

Provider Business Mailing Address
First Line	:	1905 NE STALLINGS DR STE 5
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-3805
Country	:	US
Telephone Number	:	936-560-3500
Fax Number	:	936-560-3505

Provider Business Practice Location Address
First Line	:	2618 NORTH ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-3501
Country	:	US
Telephone Number	:	936-560-3500
Fax Number	:	936-560-3505

Authorized Official
Title or Position	:	ADMINISTRATOR / CEO
Name	:	AMY LYNETTE WILCOX
Credential	:
Telephone Number	:	903-297-9300

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	05/24/2021

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