Healthcare Provider Details

I. General information

NPI: 1548656242
Provider Name (Legal Business Name): WHITE LINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 W C STREET
BASIN WY
82410
US

IV. Provider business mailing address

PO BOX 530
BASIN WY
82410-0530
US

V. Phone/Fax

Practice location:
  • Phone: 307-568-2041
  • Fax: 307-568-2727
Mailing address:
  • Phone: 307-568-2041
  • Fax: 307-568-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: CLAYTON DRAGGOO
Title or Position: OWNER
Credential:
Phone: 307-568-2041