Healthcare Provider Details

I. General information

NPI: 1457458077
Provider Name (Legal Business Name): SLEEP MANAGEMENT CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6350 TECHSTER BLVD STE 2
FORT MYERS FL
33966-4705
US

IV. Provider business mailing address

6350 TECHSTER BLVD STE 2
FORT MYERS FL
33966-4705
US

V. Phone/Fax

Practice location:
  • Phone: 239-334-8144
  • Fax: 239-210-0048
Mailing address:
  • Phone: 239-334-8144
  • Fax: 239-210-0048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA CLARK
Title or Position: PRESIDENT
Credential: MSW, RPSGT
Phone: 239-334-8144