Healthcare Provider Details

I. General information

NPI: 1699021295
Provider Name (Legal Business Name): SLEEP-WAKE DISORDER CENTER OF DAYTONA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WILDWOOD ST STE 1
DAYTONA BEACH FL
32117-4568
US

IV. Provider business mailing address

810 WILDWOOD ST STE 1
DAYTONA BEACH FL
32117-4568
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-7100
  • Fax: 386-253-1843
Mailing address:
  • Phone: 386-258-7100
  • Fax: 386-253-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: WAHBA W WAHBA
Title or Position: OWNER
Credential: MD
Phone: 386-258-7100