Basic Information
| Provider Information | |||||||||
| NPI: | 1093894685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COSTRINI SLEEP SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SLEEP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11909 MCAULEY DR UNIT A1 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129276680 | ||||||||
| FaxNumber: | 9129270062 | ||||||||
| Practice Location | |||||||||
| Address1: | 11909 MCAULEY DR UNIT A1 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129276680 | ||||||||
| FaxNumber: | 9129270062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRAYSON | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9129276680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173F00000X | 014476 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Sleep Specialist, PhD | 332B00000X | 20011763092 | GA | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207RP1001X | 014476 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 829165487A | 05 | GA | MEDICAID |