Provider Demographics
NPI:1043482540
Name:LAKELINE MEDICAL SUPPLY
Entity type:Organization
Organization Name:LAKELINE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:JON
Authorized Official - Last Name:KRUGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-633-5669
Mailing Address - Street 1:1525 CYPRESS CREEK RD STE H
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3604
Mailing Address - Country:US
Mailing Address - Phone:512-633-5669
Mailing Address - Fax:512-401-2145
Practice Address - Street 1:1525 CYPRESS CREEK RD STE H
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3604
Practice Address - Country:US
Practice Address - Phone:512-633-5669
Practice Address - Fax:512-401-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0103078332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies