1164441309 NPI number — SLEEP DISORDER CENTER FT WALTON BEACH INC

Table of content: (NPI 1164441309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164441309 NPI number — SLEEP DISORDER CENTER FT WALTON BEACH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLEEP DISORDER CENTER FT WALTON BEACH INC
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:
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:
1164441309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
502 E PINE AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32539-2818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-689-5496
Provider Business Mailing Address Fax Number:
850-689-5497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 MARY ESTHER BLVD STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARY ESTHER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32569-1985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-689-5496
Provider Business Practice Location Address Fax Number:
850-689-5497
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RODGERS
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
LAB SUPERVISOR
Authorized Official Telephone Number:
850-689-5496

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)





Copyright © 2007-2025 www.npivalidator.com