1487856084 NPI number — SLEEP CONSULTANTS DIAGNOSTIC LAB

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 1487856084 NPI number — SLEEP CONSULTANTS DIAGNOSTIC LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLEEP CONSULTANTS DIAGNOSTIC LAB
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:
1487856084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 TOWNE CENTER BLVD
Provider Second Line Business Mailing Address:
STE 101A
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-4843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-982-7111
Provider Business Mailing Address Fax Number:
601-981-2524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 TOWNE CENTER BLVD
Provider Second Line Business Practice Location Address:
STE 101A
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39157-4843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-982-7111
Provider Business Practice Location Address Fax Number:
601-981-2524
Provider Enumeration Date:
06/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROSE
Authorized Official First Name:
JULIAN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-982-7111

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS1200X , with the licence number: 08416 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: 08416 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 302G708148 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00010055 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".