Provider Demographics
NPI:1003050444
Name:STATE LINE SURGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:STATE LINE SURGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER OF ABS
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DINH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-258-0326
Mailing Address - Street 1:6339 E SPEEDWAY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-1147
Mailing Address - Country:US
Mailing Address - Phone:520-323-8732
Mailing Address - Fax:520-547-1865
Practice Address - Street 1:1310 EASTSIDE CENTRE CT # 6-142
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2705
Practice Address - Country:US
Practice Address - Phone:520-323-8732
Practice Address - Fax:520-547-1865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization