Provider Demographics
NPI:1861401861
Name:PROLINE MEDICAL CONSULTANTS, INC.
Entity type:Organization
Organization Name:PROLINE MEDICAL CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SALES MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HALYARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-505-8133
Mailing Address - Street 1:102 WHITE PARK DR
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0973
Mailing Address - Country:US
Mailing Address - Phone:770-505-8133
Mailing Address - Fax:770-505-8315
Practice Address - Street 1:102 WHITE PARK DR
Practice Address - Street 2:SUITE 300A
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-0973
Practice Address - Country:US
Practice Address - Phone:770-505-8133
Practice Address - Fax:770-505-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA200115969818332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA938214730AMedicaid
GA938214730AMedicaid