Basic Information
| Provider Information | |||||||||
| NPI: | 1184744286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGITRACE CARE SERVICES INC | ||||||||
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| OtherOrganizationName: | SLEEPMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 2417 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722393494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 11/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | IBERGER | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP-CFO | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | PL7236 | 01 | TX | BLUE CROSS | OTHER | 126657902 | 05 | TX | MEDICAID | 0085DC | 01 | TX | BLUE CROSS | OTHER | PL7237 | 01 | TX | BLUE CROSS | OTHER |