=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902134786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL SLEEP DIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2009
-----------------------------------------------------
Last Update Date | 12/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 ATKINSON RD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-5602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-736-6604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 ATKINSON RD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-5602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-736-6604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. LEWIS SHAWN SHORT
-----------------------------------------------------
Credential | RPSGT.
-----------------------------------------------------
Telephone | 678-736-6604
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number | 1004
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------