Provider Demographics
NPI:1174705859
Name:LIFELINE EMS LLC
Entity type:Organization
Organization Name:LIFELINE EMS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:TACITO
Authorized Official - Suffix:
Authorized Official - Credentials:EMT
Authorized Official - Phone:901-619-3127
Mailing Address - Street 1:510 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4336
Mailing Address - Country:US
Mailing Address - Phone:870-735-9718
Mailing Address - Fax:870-735-9718
Practice Address - Street 1:510 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4336
Practice Address - Country:US
Practice Address - Phone:870-735-9718
Practice Address - Fax:870-735-9718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000100183416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186922715Medicaid
TNT000212Medicaid
AR47420Medicare PIN
TNT000212Medicaid