Healthcare Provider Details

I. General information

NPI: 1679653109
Provider Name (Legal Business Name): SLEEP LAB OF NORTHEASTERN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 NORTHERN BLVD SUITE 2
CLARKS SUMMIT PA
18411-9189
US

IV. Provider business mailing address

231 NORTHERN BLVD SUITE 2
CLARKS SUMMIT PA
18411-9189
US

V. Phone/Fax

Practice location:
  • Phone: 570-585-6220
  • Fax: 570-585-6234
Mailing address:
  • Phone: 570-585-6220
  • Fax: 570-585-6234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. DAVID P. WASHO
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: RPSGT, RRT
Phone: 570-585-6220