Healthcare Provider Details

I. General information

NPI: 1508093469
Provider Name (Legal Business Name): OMNISLEEP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

3810 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-8758
  • Fax: 505-843-9269
Mailing address:
  • Phone: 505-843-8758
  • Fax: 505-843-9269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN CRAIG EAVES
Title or Position: CEO
Credential:
Phone: 505-843-8758