=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902554033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE SLEEP PROFESSIONALS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2022
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 FIELD ST
-----------------------------------------------------
City | BREMEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30110-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-538-1624
-----------------------------------------------------
Fax | 770-299-4349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 FIELD ST
-----------------------------------------------------
City | BREMEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30110-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-538-1624
-----------------------------------------------------
Fax | 770-299-4349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TINA GARRETT
-----------------------------------------------------
Credential | BS, RPSGT, RST, CCSH
-----------------------------------------------------
Telephone | 770-538-1624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------