=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376863761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COR DIAGNOSTIC SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2010
-----------------------------------------------------
Last Update Date | 06/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 BIG HORN RD UNIT 2F
-----------------------------------------------------
City | VAIL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81657-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-331-6098
-----------------------------------------------------
Fax | 970-300-1813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4932
-----------------------------------------------------
City | VAIL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81658-4932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-331-6098
-----------------------------------------------------
Fax | 970-300-1813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SALES
-----------------------------------------------------
Name | MR. SHAUN G MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-331-6098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------