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General NPI Number Information
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NPI Number | 1275545923
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Entity Type | Organization
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Legal Business Name | SOUTH CENTRAL REGIONAL SLEEP LAB
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1220 JEFFERSON ST
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City | LAUREL
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State | MS
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Zip | 39440-4355
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Country | US
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Telephone | 601-426-4530
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6511
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City | LAUREL
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State | MS
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Zip | 39441-6511
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Country | US
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Telephone | 601-426-4530
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | JOHN M. WALLACE
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Credential | M.D.
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Telephone | 601-426-4530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 293D00000X
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Taxonomy Name | Physiological Laboratory
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License Number |
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License Number State |
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