Provider Demographics
NPI:1538199773
Name:COUNTY LINE MEDICAL SERVICE INC
Entity type:Organization
Organization Name:COUNTY LINE MEDICAL SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYONG
Authorized Official - Middle Name:YOL
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-824-5007
Mailing Address - Street 1:545 S COUNTY LINE DR SPC A
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081-7802
Mailing Address - Country:US
Mailing Address - Phone:575-824-5007
Mailing Address - Fax:
Practice Address - Street 1:545 S COUNTY LINE DR SPC A
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7802
Practice Address - Country:US
Practice Address - Phone:575-824-5007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF0606OtherRR MEDICARE
NM40725391Medicaid
NM800521178Medicare PIN