Healthcare Provider Details

I. General information

NPI: 1104831809
Provider Name (Legal Business Name): INDIANOLA SLEEP CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W JACKSON ST
BELZONI MS
39038-3500
US

IV. Provider business mailing address

PO BOX 1151
MADISON MS
39130-1151
US

V. Phone/Fax

Practice location:
  • Phone: 662-887-3700
  • Fax: 888-519-3773
Mailing address:
  • Phone: 662-887-3700
  • Fax: 888-519-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN K HERRING
Title or Position: MEMBER
Credential:
Phone: 662-887-3700