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General NPI Number Information
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NPI Number | 1992850671
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Entity Type | Organization
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Legal Business Name | IDAHO DIAGNOSTIC SLEEP LAB, INC.
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 526 SHOUP AVE W STE C
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City | TWIN FALLS
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State | ID
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Zip | 83301-5050
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Country | US
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Telephone | 208-736-7646
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Fax | 208-736-1569
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Provider Business Mailing Address
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Address Line | 526 SHOUP AVE W STE C
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City | TWIN FALLS
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State | ID
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Zip | 83301-5050
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Country | US
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Telephone | 208-736-7646
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Fax | 208-736-1569
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. SEAN D CHRISTENSEN
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Credential |
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Telephone | 208-736-7646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1200X
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Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
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License Number | 002743400
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License Number State | ID
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