=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477047926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO SLEEP AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2018
-----------------------------------------------------
Last Update Date | 06/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 W CAYUSE CREEK DR STE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-4757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-899-2384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 W CAYUSE CREEK DR STE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-4757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-9252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MATTHEW L KOOYMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-899-2384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-3565
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | D-3565
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------