=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588943757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMETTO SLEEP LAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2011
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1207 LAKESIDE DR UNIT B
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29526-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-234-4900
-----------------------------------------------------
Fax | 843-234-4901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1226
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29578-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-444-0800
-----------------------------------------------------
Fax | 843-444-0881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRY MILTON CAPELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-444-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------