=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093160350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLEEP APNEA & BREATHING THERAPY NORTHWEST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2016
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2615 N FRUITLAND LN
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-7914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-660-4880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2615 N FRUITLAND LN
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-7914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-660-4880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | GEORGE J LOFTUS III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-660-4880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3019
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 3019
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------