Basic Information
Provider Information | |||||||||
NPI: | 1073610341 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MISSISSIPPI VALLEY SLEEP DISORDER CENTER LC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MVSDC-PREMIER SLEEP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1230 E RUSHOLME ST | ||||||||
Address2: | STE 303 | ||||||||
City: | DAVENPORT | ||||||||
State: | IA | ||||||||
PostalCode: | 528032400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5633222036 | ||||||||
FaxNumber: | 5633238240 | ||||||||
Practice Location | |||||||||
Address1: | 242 N BLUFF BLVD | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | IA | ||||||||
PostalCode: | 527327119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5632424233 | ||||||||
FaxNumber: | 5632424231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 05/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHAMBERLIN | ||||||||
AuthorizedOfficialFirstName: | JOANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5633222036 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN, BS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 0469411 | 05 | IA |   | MEDICAID |