MEDICARE: LIFELINE REGIONAL AMBULANCE, INC.

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	3416L0300X	Land Ambulance	077	SC

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	:	1164539284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE REGIONAL AMBULANCE, INC.

Provider Business Mailing Address
First Line	:	239 N ACLINE ST
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2159
Country	:	US
Telephone Number	:	843-374-3911
Fax Number	:	843-394-9111

Provider Business Practice Location Address
First Line	:	239 N ACLINE ST
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2159
Country	:	US
Telephone Number	:	843-374-3911
Fax Number	:	843-394-9111

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOSEPH LANCE LANE
Credential	:	EMT
Telephone Number	:	843-374-3911

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	06/24/2014

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