Healthcare Provider Details

I. General information

NPI: 1124115894
Provider Name (Legal Business Name): SOUTHERN MISSOURI SLEEP CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 BARRON RD STE 117
POPLAR BLUFF MO
63901-1922
US

IV. Provider business mailing address

PO BOX 771933
SAINT LOUIS MO
63177-1933
US

V. Phone/Fax

Practice location:
  • Phone: 573-727-9661
  • Fax: 573-727-9665
Mailing address:
  • Phone: 573-727-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNDA NEWMAN
Title or Position: DIRECTOR OF PATIENT CARE
Credential:
Phone: 314-645-5855