Healthcare Provider Details

I. General information

NPI: 1164066320
Provider Name (Legal Business Name): SWALLOWTAIL SLEEP CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 09/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 WALES AVE NW STE J
MASSILLON OH
44646-2367
US

IV. Provider business mailing address

2400 WALES AVE NW STE J
MASSILLON OH
44646-2367
US

V. Phone/Fax

Practice location:
  • Phone: 330-904-7753
  • Fax:
Mailing address:
  • Phone: 330-832-4533
  • Fax: 330-832-3500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD MOSHER
Title or Position: OWNER
Credential:
Phone: 330-904-7753