Healthcare Provider Details

I. General information

NPI: 1528265709
Provider Name (Legal Business Name): SLEEP CENTERS OF FORT WAYNE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7223 ENGLE RD STE 110
FORT WAYNE IN
46804-2239
US

IV. Provider business mailing address

7223 ENGLE RD STE 110
FORT WAYNE IN
46804-2239
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-6450
  • Fax: 260-969-6451
Mailing address:
  • Phone: 260-969-6450
  • Fax: 260-969-6451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN R. SMITH
Title or Position: PRESIDENT
Credential:
Phone: 260-969-6450