1104831809 NPI number — INDIANOLA SLEEP CLINIC, LLC

Table of content: (NPI 1104831809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104831809 NPI number — INDIANOLA SLEEP CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANOLA SLEEP CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104831809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39130-1151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-887-3700
Provider Business Mailing Address Fax Number:
888-519-3773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 W JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELZONI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39038-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-887-3700
Provider Business Practice Location Address Fax Number:
888-519-3773
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERRING
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
662-887-3700

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05073893 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20335479 . This is a "TRICARE PROVIDER ID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com