=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154526655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTUCKY SLEEP DISORDER CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1006 NEW MOODY LN
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-9122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-222-0030
-----------------------------------------------------
Fax | 502-222-0390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1006 NEW MOODY LN
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-9122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-222-0030
-----------------------------------------------------
Fax | 502-222-0390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED AGENT
-----------------------------------------------------
Name | MS. NISHA DAVE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-222-0030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------