=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356417331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE SLEEP DIAGNOSTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 S MUSTANG RD
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-7316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-265-3100
-----------------------------------------------------
Fax | 405-253-4148
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2421 WILCOX DR
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-3956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-265-3100
-----------------------------------------------------
Fax | 405-253-4148
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MRS. MEAGHAN RHEA MCKENZIE
-----------------------------------------------------
Credential | RRT
-----------------------------------------------------
Telephone | 405-265-3100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------