=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326276262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLEEP DISORDERS CENTER OF PRESCOTT VALLEY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2009
-----------------------------------------------------
Last Update Date | 09/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1840 MESQUITE AVE STE B LAKE HAVASU CITY
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-453-9199
-----------------------------------------------------
Fax | 928-453-9207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3270
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86405-3270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-453-9199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SUPERVISOR
-----------------------------------------------------
Name | MELANIE GAYLE MUNDELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-453-9199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------