Basic Information
| Provider Information | |||||||||
| NPI: | 1184832354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME HEALTHCARE (SLEEP LAB) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 ISHAM RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061072204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605212231 | ||||||||
| FaxNumber: | 8605212238 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2007 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | BRUNO | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8602630253 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.