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General NPI Number Information
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NPI Number | 1114421260
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Entity Type | Organization
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Legal Business Name | STATELINE MEDICAL LLC
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Dates
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Enumeration Date | 03/22/2018
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Last Update Date | 03/22/2018
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Provider Practice Location Address
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Address Line | 105 N POCOLA BLVD SUITE 2
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City | POCOLA
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State | OK
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Zip | 74902-3101
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Country | US
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Telephone | 479-561-2448
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Fax |
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Provider Business Mailing Address
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Address Line | 105 N POCOLA BLVD SUITE 2
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City | POCOLA
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State | OK
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Zip | 74902-3101
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Country | US
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Telephone | 479-561-2448
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHANE WALKER
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Credential | D.C.
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Telephone | 479-561-2448
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State | OK
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