Provider Demographics
NPI:1568949436
Name:STATELINE MEDICAL AR LLC
Entity Type:Organization
Organization Name:STATELINE MEDICAL AR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-650-9459
Mailing Address - Street 1:17 BELHAVEN VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-9063
Mailing Address - Country:US
Mailing Address - Phone:479-650-9459
Mailing Address - Fax:
Practice Address - Street 1:12204 W HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-9560
Practice Address - Country:US
Practice Address - Phone:479-561-2448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory