Basic Information
| Provider Information | |||||||||
| NPI: | 1659346062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI VALLEY SLEEP DISORDER CENTER LC | ||||||||
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| OtherOrganizationName: | MVSDC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 E RUSHOLME ST | ||||||||
| Address2: | STE 303 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633222036 | ||||||||
| FaxNumber: | 5633238240 | ||||||||
| Practice Location | |||||||||
| Address1: | 3385 DEXTER CT | ||||||||
| Address2: | STE 102 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528073471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633446750 | ||||||||
| FaxNumber: | 5633446751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERLIN | ||||||||
| AuthorizedOfficialFirstName: | JOANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5633222036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN, BS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0469411 | 05 | IA | MEDICAID | 0427146 | 05 | IA | MEDICAID |