=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417377128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURCELLVILLE SLEEP CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2014
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N MAPLE AVE
-----------------------------------------------------
City | PURCELLVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20132-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-338-0032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 N MAPLE AVE
-----------------------------------------------------
City | PURCELLVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20132-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-338-0032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. IRFAN IDREES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 540-338-0032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------