Healthcare Provider Details

I. General information

NPI: 1780120006
Provider Name (Legal Business Name): LAKESIDE SLEEP CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 BLUE HERON DR STE 102
MONTGOMERY TX
77316-3192
US

IV. Provider business mailing address

123 BLUE HERON DR STE 102
MONTGOMERY TX
77316-3192
US

V. Phone/Fax

Practice location:
  • Phone: 936-582-1112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number1000226
License Number StateTX

VIII. Authorized Official

Name: CORTNIE WELLMAN
Title or Position: OWNER
Credential:
Phone: 936-582-1112