Healthcare Provider Details

I. General information

NPI: 1235118522
Provider Name (Legal Business Name): SLEEP DISORDERS CENTER OF WYOMING VALLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WELLES ST SUITE 116
FORTY FORT PA
18704-4968
US

IV. Provider business mailing address

190 WELLES ST SUITE 116
FORTY FORT PA
18704-4968
US

V. Phone/Fax

Practice location:
  • Phone: 570-331-2651
  • Fax: 570-331-2653
Mailing address:
  • Phone: 570-331-2651
  • Fax: 570-331-2653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number077098
License Number StatePA

VIII. Authorized Official

Name: DR. JOHN J DELLA ROSA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 570-331-2651