=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629473558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLTRINSIC SLEEP NETWORK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2014
-----------------------------------------------------
Last Update Date | 11/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2510 N FRONTAGE RD STE 201
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-481-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2510 N FRONTAGE RD STE 201
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-481-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | LAWRENCE J EPSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 331-481-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------