Basic Information
| Provider Information | |||||||||
| NPI: | 1467682427 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SLEEP EVALUATION CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W STONE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232475197 | ||||||||
| FaxNumber: | 4232475254 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 MEADOWVIEW PKWY | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376607332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232479075 | ||||||||
| FaxNumber: | 4232457953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 10/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232475197 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | 1518604 | 05 | TN | MEDICAID | 103G477120 | 01 | TN | MEDICARE PTAN | OTHER | 1467682427 | 05 | VA | MEDICAID |