MEDICARE: LIFELINE MEDICAL SUPPLY

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

General Provider Information

NPI Number	:	1922385194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE MEDICAL SUPPLY

Provider Business Mailing Address
First Line	:	1802 ROCKAWAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5006
Country	:	US
Telephone Number	:	646-702-7518
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 ROCKAWAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5006
Country	:	US
Telephone Number	:	646-702-7518
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. SHAKA ISAAC EROJE
Credential	:	MD
Telephone Number	:	646-702-7518

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	11/15/2011

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