Healthcare Provider Details

I. General information

NPI: 1134360217
Provider Name (Legal Business Name): PACIFIC SLEEP MEDICINE, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 17TH AVE SUITE A-20
SEATTLE WA
98122-5711
US

IV. Provider business mailing address

10532 ACACIA ST B-4
RANCHO CUCAMONGA CA
91730-5446
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-4744
  • Fax: 206-215-1135
Mailing address:
  • Phone: 909-481-2577
  • Fax: 909-418-2546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. NANCY M JOHNSON
Title or Position: CREDENTIALING
Credential:
Phone: 909-481-2577