=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679780787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLEEP DIAGNOSTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2876 SYCAMORE DR STE 301B
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93065-1550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-578-3939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 55725
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91413-0725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MIKE BERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-578-3939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1257901
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------