=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568949436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATELINE MEDICAL AR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2018
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12204 W HIGHWAY 62
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72730-9560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-561-2448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 BELHAVEN VIEW CT
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72908-9063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-650-9459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | BRITTANY FOX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-650-9459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------