Healthcare Provider Details

I. General information

NPI: 1184969420
Provider Name (Legal Business Name): ADVANCED SLEEP INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2731 WEST MAIN SUITE C
CARBONDALE IL
62901-1000
US

IV. Provider business mailing address

PO BOX 459
CARBONDALE IL
62903-0459
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9999
  • Fax:
Mailing address:
  • Phone: 618-355-9970
  • Fax: 618-355-9972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: RACHEL SHELTON
Title or Position: FACILITY MANAGER
Credential:
Phone: 618-549-6378