=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972979482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAINLAND AMERICAN SLEEP DIAGNOSTICS CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2015
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 W FAIRMONT PKWY STE F
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-218-6990
-----------------------------------------------------
Fax | 281-218-7969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 580313
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77258-0313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-218-6990
-----------------------------------------------------
Fax | 281-218-7969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DEVIN CLENNON
-----------------------------------------------------
Credential | RPSGT, RST
-----------------------------------------------------
Telephone | 281-218-6990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1001276
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------