Healthcare Provider Details

I. General information

NPI: 1245381185
Provider Name (Legal Business Name): TIMBERLINE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 E WHITE MOUNTAIN BLVD
PINETOP AZ
85935
US

IV. Provider business mailing address

PO BOX 2310
PINETOP AZ
85935-2310
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-6834
  • Fax:
Mailing address:
  • Phone: 928-367-6834
  • Fax: 928-367-6838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number07058139W
License Number StateAZ

VIII. Authorized Official

Name: JERRY LIGE ARMSTRONG
Title or Position: OWNER
Credential:
Phone: 928-367-6834