1013280445 NPI number — SLEEP SOLUTIONS OF CENTRAL ILLINOIS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013280445 NPI number — SLEEP SOLUTIONS OF CENTRAL ILLINOIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLEEP SOLUTIONS OF CENTRAL ILLINOIS 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:
1013280445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2309 E EMPIRE ST
Provider Second Line Business Mailing Address:
STE. 500
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61704-8636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-319-6568
Provider Business Mailing Address Fax Number:
309-664-0352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 E EMPIRE ST
Provider Second Line Business Practice Location Address:
STE. 500
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61704-8636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-319-6568
Provider Business Practice Location Address Fax Number:
309-664-0352
Provider Enumeration Date:
02/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
309-319-6568

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019021753 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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