1629032149 NPI number — SLEEP LABS OF THE DEEP SOUTH LLC

Table of content: (NPI 1629032149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629032149 NPI number — SLEEP LABS OF THE DEEP SOUTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLEEP LABS OF THE DEEP SOUTH 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:
1629032149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
382 B CARRIAGE HOUSE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38305-2299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-664-8716
Provider Business Mailing Address Fax Number:
731-664-8932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13702 COURSEY BOULEVARD
Provider Second Line Business Practice Location Address:
BUILDING 4 SUITE A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70817-1370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-925-3357
Provider Business Practice Location Address Fax Number:
225-924-9863
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAYLORD
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
ESTELLE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
225-925-3357

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: G6949 . This is a "BCBS LA" identifier . This identifiers is of the category "OTHER".




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