Healthcare Provider Details

I. General information

NPI: 1811125396
Provider Name (Legal Business Name): CGC SLEEP LAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43920 MARGARITA RD SUITE G
TEMECULA CA
92592-2736
US

IV. Provider business mailing address

43920 MARGARITA RD SUITE G
TEMECULA CA
92592-2736
US

V. Phone/Fax

Practice location:
  • Phone: 951-402-5076
  • Fax: 951-302-4890
Mailing address:
  • Phone: 951-402-5076
  • Fax: 951-302-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number200908210422
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number200908210422
License Number StateCA

VIII. Authorized Official

Name: MR. LEONARD JOAQUIN SANTOS
Title or Position: PRESIDENT
Credential:
Phone: 951-402-5076