MEDICARE: LIFE LINE HOME CARE 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	332B00000X	Durable Medical Equipment & Medical Supplies	GBU20140244	GA

General Provider Information

NPI Number	:	1316355076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE LINE HOME CARE INC

Provider Business Mailing Address
First Line	:	1610 MADISON AVE
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-3756
Country	:	US
Telephone Number	:	912-777-6635
Fax Number	:	912-777-6654

Provider Business Practice Location Address
First Line	:	6409 ABERCORN ST
Second Line	:	SUITE F
City	:	SAVANNAH
State	:	GA
Zip	:	31405-5715
Country	:	US
Telephone Number	:	912-777-6635
Fax Number	:	912-777-6654

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RONNIE C DANIEL
Credential	:	PHARMD
Telephone Number	:	229-382-1334

Provider Enumeration Date	:	07/25/2014
Last Update Date	:	07/25/2014

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