Basic Information
Provider Information | |||||||||
NPI: | 1831263912 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMPLETE SLEEP ANALYSIS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10532 ACACIA ST | ||||||||
Address2: | SUITE B-4 | ||||||||
City: | RANCHO CUCAMONGA | ||||||||
State: | CA | ||||||||
PostalCode: | 917305446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094812577 | ||||||||
FaxNumber: | 6026827632 | ||||||||
Practice Location | |||||||||
Address1: | 4226 AVENIDA COCHISE | ||||||||
Address2: | SUITE 10 | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856355818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204598618 | ||||||||
FaxNumber: | 5204582865 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 10/31/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 9094812577 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.