Healthcare Provider Details

I. General information

NPI: 1295883718
Provider Name (Legal Business Name): SLEEP SOURCE KENTUCKY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 6TH ST
MURRAY KY
42071-2000
US

IV. Provider business mailing address

3125 PARISA DR
PADUCAH KY
42003-4584
US

V. Phone/Fax

Practice location:
  • Phone: 270-768-0080
  • Fax: 270-768-0081
Mailing address:
  • Phone: 270-575-0080
  • Fax: 270-575-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3618
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3618
License Number StateKY

VIII. Authorized Official

Name: MR. MARK SEXTON
Title or Position: CO-OWNER
Credential:
Phone: 270-575-0080