Healthcare Provider Details

I. General information

NPI: 1164441309
Provider Name (Legal Business Name): SLEEP DISORDER CENTER FT WALTON BEACH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MARY ESTHER BLVD STE 203
MARY ESTHER FL
32569-1985
US

IV. Provider business mailing address

502 E PINE AVE STE A
CRESTVIEW FL
32539-2818
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-5496
  • Fax: 850-689-5497
Mailing address:
  • Phone: 850-689-5496
  • Fax: 850-689-5497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVE A RODGERS
Title or Position: LAB SUPERVISOR
Credential: RPSGT
Phone: 850-689-5496