| Organization Name: | LAKELINE MEDICAL SUPPLY |
| NPI Number: | 1043482540 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TYSON JON KRUGMAN (OWNER) |
| Mailing Address: | 1525 Cypress Creek Rd Ste H Cedar Park |
| State: | TX US |
| Postal Code: | 786133604 |
| Phone Number: | 5126335669 |
| Fax Number: | 5124012145 |
| NPI Enumeration Date: | 03/25/2008 |
| NPI Last Update Date: | 03/25/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | 0103078 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |