Healthcare Provider Details

I. General information

NPI: 1972663342
Provider Name (Legal Business Name): SOUTHEAST SLEEP CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125C N SUMMITT ST.
CRESCENT CITY FL
32112
US

IV. Provider business mailing address

1125C N SUMMITT ST.
CRESCENT CITY FL
32112
US

V. Phone/Fax

Practice location:
  • Phone: 327-698-4418
  • Fax:
Mailing address:
  • Phone: 327-698-4418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number20063092
License Number StateFL

VIII. Authorized Official

Name: MR. KENNETH HOWARD
Title or Position: PRESIDENT
Credential:
Phone: 327-698-4418