Healthcare Provider Details

I. General information

NPI: 1457655698
Provider Name (Legal Business Name): DELTA SLEEP'S CPAP STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 E WASHINGTON ST STE. D4
BLOOMINGTON IL
61704-4472
US

IV. Provider business mailing address

2416 E WASHINGTON ST STE. D4
BLOOMINGTON IL
61704-4472
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-2727
  • Fax: 309-663-1818
Mailing address:
  • Phone: 309-663-2727
  • Fax: 309-663-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE JOSEPH LEHANE II
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 309-663-2727