1689106387 NPI number — SLEEP APNEA CARE AND WELLNESS, LLC

Table of content: (NPI 1689106387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689106387 NPI number — SLEEP APNEA CARE AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLEEP APNEA CARE AND WELLNESS, 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:
KOALA CENTER FOR SLEEP DISORDERS WI-4
Provider Other Organization Name Type Code:
3
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:
1689106387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11825 STATE ROUTE 40
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DUNLAP
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61525-8842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-839-9941
Provider Business Mailing Address Fax Number:
309-807-3365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 COUNTY ROAD HH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLOVER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54467-2653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-341-5001
Provider Business Practice Location Address Fax Number:
715-341-8983
Provider Enumeration Date:
03/31/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BARR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
715-341-5001

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3272-15 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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