Healthcare Provider Details

I. General information

NPI: 1275759441
Provider Name (Legal Business Name): IDAHO SLEEP SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 GEORGIA AVE STE 120
NAMPA ID
83686
US

IV. Provider business mailing address

PO BOX 3291
SALT LAKE CITY UT
84110-3291
US

V. Phone/Fax

Practice location:
  • Phone: 208-442-8222
  • Fax: 208-442-8232
Mailing address:
  • Phone: 208-375-8222
  • Fax: 208-375-8232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM9815
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateID
# 5
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number StateID

VIII. Authorized Official

Name: DR. DONALD J BEASLEY
Title or Position: MANAGER
Credential: MD
Phone: 208-463-3000