Healthcare Provider Details

I. General information

NPI: 1487856084
Provider Name (Legal Business Name): SLEEP CONSULTANTS DIAGNOSTIC LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 TOWNE CENTER BLVD STE 101A
RIDGELAND MS
39157-4843
US

IV. Provider business mailing address

403 TOWNE CENTER BLVD STE 101A
RIDGELAND MS
39157-4843
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-7111
  • Fax: 601-981-2524
Mailing address:
  • Phone: 601-982-7111
  • Fax: 601-981-2524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number08416
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number08416
License Number StateMS

VIII. Authorized Official

Name: DR. JULIAN F ROSE
Title or Position: OWNER
Credential: MD
Phone: 601-982-7111