MEDICARE: LIFELINE PRIVATE DUTY HOME HEALTH 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	251E00000X	Home Health Agency	7471	OK

General Provider Information

NPI Number	:	1932104817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE PRIVATE DUTY HOME HEALTH CARE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1348
Second Line	:
City	:	CHICKASHA
State	:	OK
Zip	:	73023-1348
Country	:	US
Telephone Number	:	405-224-4891
Fax Number	:	405-224-4895

Provider Business Practice Location Address
First Line	:	917 S 4TH ST
Second Line	:
City	:	CHICKASHA
State	:	OK
Zip	:	73018-4655
Country	:	US
Telephone Number	:	405-224-4891
Fax Number	:	405-224-4895

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. KELLY D JEANIS
Credential	:	RN
Telephone Number	:	405-224-4891

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/22/2020

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