Provider Demographics
NPI:1306645577
Name:LIFELINE TESTS INCORPORATED
Entity type:Organization
Organization Name:LIFELINE TESTS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-894-1615
Mailing Address - Street 1:296 ATLANTIC AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4243
Mailing Address - Country:US
Mailing Address - Phone:616-894-1615
Mailing Address - Fax:
Practice Address - Street 1:296 ATLANTIC AVE STE A
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-4243
Practice Address - Country:US
Practice Address - Phone:616-894-1615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty