MEDICARE: AMERICAN SLEEP DIAGNOSTICS LLC

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	291U00000X	Clinical Medical Laboratory		MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396779567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN SLEEP DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	PO BOX 660
Second Line	:
City	:	LONG BEACH
State	:	MS
Zip	:	39560-0660
Country	:	US
Telephone Number	:	228-865-3998
Fax Number	:	228-865-1665

Provider Business Practice Location Address
First Line	:	106 WILLOW CREEK DR
Second Line	:
City	:	LONG BEACH
State	:	MS
Zip	:	39560-3311
Country	:	US
Telephone Number	:	228-865-3998
Fax Number	:	228-865-1665

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. LAWRENCE JASPER GRAVES
Credential	:	DDS
Telephone Number	:	228-897-1636

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/22/2020

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