MEDICARE: BURBANK SLEEP TECHNOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173F00000X	Sleep Specialist (PhD)	G36302	CA

General Provider Information

NPI Number	:	1083887806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURBANK SLEEP TECHNOLOGY

Provider Business Mailing Address
First Line	:	421 E ANGELENO AVE
Second Line	:	STE: 206
City	:	BURBANK
State	:	CA
Zip	:	91501-2286
Country	:	US
Telephone Number	:	310-984-6949
Fax Number	:	323-290-3846

Provider Business Practice Location Address
First Line	:	311 N ROBERTSON BLVD
Second Line	:	STE: 609
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1705
Country	:	US
Telephone Number	:	310-984-6949
Fax Number	:	323-290-3846

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. GARY E FORD
Credential	:	M.D.
Telephone Number	:	310-984-6949

Provider Enumeration Date	:	04/12/2008
Last Update Date	:	04/12/2008

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