Provider Demographics
NPI:1487275699
Name:STATELINE MEDICAL LAB LLC
Entity type:Organization
Organization Name:STATELINE MEDICAL LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOOLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-414-5680
Mailing Address - Street 1:105 N POCOLA BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:POCOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74902-3101
Mailing Address - Country:US
Mailing Address - Phone:918-436-5001
Mailing Address - Fax:
Practice Address - Street 1:105 N POCOLA BLVD STE 2
Practice Address - Street 2:
Practice Address - City:POCOLA
Practice Address - State:OK
Practice Address - Zip Code:74902-3101
Practice Address - Country:US
Practice Address - Phone:918-436-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory