Healthcare Provider Details

I. General information

NPI: 1619343092
Provider Name (Legal Business Name): USA SLEEP DIAGNOSTIC MOBILE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 ANNAPOLIS RD STE 202
ODENTON MD
21113-1349
US

IV. Provider business mailing address

6030 DAYBREAK CIR STE A150260
CLARKSVILLE MD
21029-1642
US

V. Phone/Fax

Practice location:
  • Phone: 888-792-4445
  • Fax: 888-765-6615
Mailing address:
  • Phone: 888-792-4445
  • Fax: 888-765-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number20179
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: THURLYN BRYAN WILSON
Title or Position: CEO
Credential:
Phone: 888-792-4445