Basic Information
| Provider Information | |||||||||
| NPI: | 1477587145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IN YOUR DREAMS INTERNATIONAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EMERALD COAST SLEEP DISORDERS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | 9785359757 | ||||||||
| Practice Location | |||||||||
| Address1: | 4566 E HIGHWAY 20 | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325788838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507293930 | ||||||||
| FaxNumber: | 8507293933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE & ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 94735 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | V00E7 | 01 | FL | BCBS OF FLORIDA | OTHER |