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	1312767	FL
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	1312767	FL
3	333600000X	Pharmacy	PH24359	FL
4	3336C0004X	Compounding Pharmacy	PH24359	FL
5	3336H0001X	Home Infusion Therapy Pharmacy	PH24359	FL
6	3336S0011X	Specialty Pharmacy	PH24359	FL
7	332BX2000X	Oxygen Equipment & Supplies (DME)	324181	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0942290002	OTHER	FL	MEDICARE

General Provider Information

NPI Number	:	1578630190
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	:	904-730-2202
Fax Number	:	904-730-2212

Provider Business Practice Location Address
First Line	:	3740 SAINT JOHNS BLUFF RD S
Second Line	:	SUITE 1
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-2651
Country	:	US
Telephone Number	:	904-730-2202
Fax Number	:	904-730-2212

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	09/10/2012

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Directions to “LIFE LINE HOME CARE INC ” Practice Location

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