Healthcare Provider Details

I. General information

NPI: 1851550974
Provider Name (Legal Business Name): WARREN S LINE JR MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST SUITE #320
BURBANK CA
91505
US

IV. Provider business mailing address

191 SOUTH BUENA VISTA STREET SUITE #320
BURBANK CA
91505
US

V. Phone/Fax

Practice location:
  • Phone: 818-763-7366
  • Fax: 818-763-1809
Mailing address:
  • Phone: 818-763-7366
  • Fax: 818-763-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberG48150
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG48150
License Number StateCA

VIII. Authorized Official

Name: WARREN SCOTT LINE JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 818-763-7366