=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952508178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL SLEEP LAB, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 11/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ROUTE 10 COOKPARKWAY
-----------------------------------------------------
City | OCEANA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-682-8228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1145
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24740-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-682-8228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TYAN LESTER
-----------------------------------------------------
Credential | RRT
-----------------------------------------------------
Telephone | 304-682-8228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------