Lifeline Hospice, Inc.
Organization Active NPI Community Based Hospice Care Agency · Chickasha, OK
NPI 1083619969 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1083619969
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Based Hospice Care Agency 251G00000X
- License
- 4150 (OK)
- Legal business name
- LIFELINE HOSPICE, INC.
- Practice address
- 2210 S 16TH St
Chickasha, OK 73018-6432 - Phone
- (405) 222-2051
- Fax
- (405) 222-2151
- NPI assigned
- Jun 16, 2005
- Organization subpart
- No
Authorized official
- Name
- Ms. Kelly D Jeanis, RN
- Title
- Administrator
- Phone
- (405) 224-4891
Affiliated clinicians 3
-
Abby Marie Housman, D.O.
-
Deacon Vice, D.O.
Medicare Care Compare: Hospice
- Listed as
- Lifeline Hospice, Inc.
- Ownership
- For-Profit
- Certified
- Dec 18, 2002
- Medicare certification status
- Active
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 37D1001866 | Lifeline Hospice, Inc | Certificate of waiver | Jul 22, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OK
Hospice certification: CCN 371611
- Legal name
- LIFELINE HOSPICE, INC.
- Certification status
- Active
- Provider type (POS)
- Hospice
- Participating since
- Dec 18, 2002
- Last certification
- Jun 14, 2021
- Ownership / control type
- Proprietary - Corporation
- Organization structure
- Corporation · Proprietary
- Incorporated
- Jul 3, 2002 in OK
- Enrollment address
- 1701 W Iowa
Chickasha, OK 73018-2848
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Toye L Reynolds |
5% Or Greater Direct Ownership Interest | Jul 3, 2002 | 66.6% |
| Corporate Director | Jun 12, 2003 | ||
| Kelly D Nunn |
5% Or Greater Direct Ownership Interest | Sep 7, 2012 | 33.3% |
| Corporate Director | Jun 12, 2003 | ||
| W-2 Managing Employee | Sep 7, 2012 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20030612000044 | OK | Part a Provider - Hospice | 5193635316 | Practice locations: Chickasha, OK |
National Provider Directory
Locations
917 S 4th St
Chickasha, OK 73018
Phone (405) 224-4891
2210 S 16th St
Chickasha, OK 73018
Phone (405) 222-2051
1701 W Iowa Ave
Chickasha, OK 73018
Phone (405) 222-2051
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | 4150 | OK | Yes |
Addresses
Primary practice location
2210 S 16TH St
Chickasha, OK 73018-6432
Mailing address
PO Box 1348
Chickasha, OK 73023-1348
Phone (405) 222-2051
Other providers in Chickasha, OK
- Pamela Jo Lee
- Summer Lee
- Bryan E Lehman
- Liberty Drug Inc
- Lifeline Home Health Care, Inc
- Lifeline Private Duty Home Health Care, Inc.
- Kameron Lindsay
- Paula Sue Lister
- Logsdon Chiropractic, PLLC
- Jennifer Ann Logsdon
All providers in Chickasha, OK · Community Based Hospice Care Agency in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.