Healthcare Provider Details

I. General information

NPI: 1700030731
Provider Name (Legal Business Name): SOUTHWEST INSTITUTE FOR SLEEP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15640 N 7TH ST SUITE 1
PHOENIX AZ
85022-3512
US

IV. Provider business mailing address

15640 N 7TH ST SUITE 1
PHOENIX AZ
85022-3512
US

V. Phone/Fax

Practice location:
  • Phone: 602-439-3800
  • Fax:
Mailing address:
  • Phone: 602-439-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HADDAR E ICHILOV
Title or Position: ADMINISTRATOR
Credential: P.T.
Phone: 602-439-3800