Provider Demographics
NPI:1710057187
Name:STATE LINE MEDICAL, INC
Entity Type:Organization
Organization Name:STATE LINE MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-529-8888
Mailing Address - Street 1:13693 STOWELL RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-9735
Mailing Address - Country:US
Mailing Address - Phone:734-529-8888
Mailing Address - Fax:734-529-5444
Practice Address - Street 1:13693 STOWELL RD
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:MI
Practice Address - Zip Code:48131-9735
Practice Address - Country:US
Practice Address - Phone:734-529-8888
Practice Address - Fax:734-529-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0394070001Medicare ID - Type Unspecified