Healthcare Provider Details

I. General information

NPI: 1023037272
Provider Name (Legal Business Name): SPACE COAST SLEEP DISORDERS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 CLASSIC CT SUITE 106
MELBOURNE FL
32940-8279
US

IV. Provider business mailing address

640 CLASSIC CT SUITE 106
MELBOURNE FL
32940-8279
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-9901
  • Fax: 321-255-9902
Mailing address:
  • Phone: 321-255-9901
  • Fax: 321-255-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License NumberHCC7135
License Number StateFL

VIII. Authorized Official

Name: MR. ANTONIO EDWIN STIGALL
Title or Position: PRESIDENT/CEO
Credential: RRT, RPSGT
Phone: 321-255-9901