Provider Demographics
NPI:1376859678
Name:MIDLINE LLC
Entity Type:Organization
Organization Name:MIDLINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMT, ROLFER
Authorized Official - Phone:831-421-9222
Mailing Address - Street 1:555 SOQUEL AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2320
Mailing Address - Country:US
Mailing Address - Phone:831-421-9222
Mailing Address - Fax:831-421-9229
Practice Address - Street 1:555 SOQUEL AVE STE 350
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2320
Practice Address - Country:US
Practice Address - Phone:831-421-9222
Practice Address - Fax:831-421-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAST. DOES NOT LICENSE225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty