Provider Demographics
NPI:1922763879
Name:STATELINE WELLNESS TRANSPORT LLC
Entity Type:Organization
Organization Name:STATELINE WELLNESS TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:OLIVERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-912-7850
Mailing Address - Street 1:23 GATE 11
Mailing Address - Street 2:
Mailing Address - City:CAROLINA SHORES
Mailing Address - State:NC
Mailing Address - Zip Code:28467-2621
Mailing Address - Country:US
Mailing Address - Phone:716-912-7850
Mailing Address - Fax:
Practice Address - Street 1:23 GATE 11
Practice Address - Street 2:
Practice Address - City:CAROLINA SHORES
Practice Address - State:NC
Practice Address - Zip Code:28467-2621
Practice Address - Country:US
Practice Address - Phone:716-912-7850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-05
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)