Provider Demographics
NPI:1851629356
Name:LIFE LINE SURGICAL SERVICES LLC
Entity type:Organization
Organization Name:LIFE LINE SURGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:314-591-1125
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:SUITE 330-A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-718-9947
Mailing Address - Fax:314-718-9947
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 330-A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-718-9947
Practice Address - Fax:314-718-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16010260OtherCPIN
MO1407950017OtherINDIVIDUAL NPI
MO16010260OtherCPIN