Provider Demographics
NPI:1912068180
Name:LIFE GUARD INC.
Entity type:Organization
Organization Name:LIFE GUARD INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONLUC
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-834-5370
Mailing Address - Street 1:101 LOCUST AVE.
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276
Mailing Address - Country:US
Mailing Address - Phone:304-927-6090
Mailing Address - Fax:304-927-6090
Practice Address - Street 1:101 LOCUST AVE.
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276
Practice Address - Country:US
Practice Address - Phone:304-927-6090
Practice Address - Fax:304-927-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE REQUIRED332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6202086000Medicaid
WV0235060009Medicare ID - Type UnspecifiedMEDICARE