| Organization Name: | STATE LINE SURGICAL SERVICES, LLC |
| NPI Number: | 1003050444 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LACEY DINH (REVENUE CYCLE MANAGER OF ABS) |
| Mailing Address: | 1310 Eastside Centre Ct # 6-142 Mountain Home |
| State: | AR US |
| Postal Code: | 726532705 |
| Phone Number: | 5203238732 |
| Fax Number: | 5205471865 |
| NPI Enumeration Date: | 04/29/2009 |
| NPI Last Update Date: | 12/16/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 302R00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AR |
| Taxonomy Type: | Managed Care Organizations |
| Taxonomy Classification: | Health Maintenance Organization |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) A form of health insurance in which its members prepay a premium for the HMO |