MEDICARE: IDAHO SLEEP AND WELLNESS 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	122300000X	Dentist	D-3565	ID
2	332BC3200X	Customized Equipment (DME)	D-3565	ID

General Provider Information

NPI Number	:	1477047926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO SLEEP AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	1500 W CAYUSE CREEK DR STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-4757
Country	:	US
Telephone Number	:	208-888-9252
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 W CAYUSE CREEK DR STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-4757
Country	:	US
Telephone Number	:	208-899-2384
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATTHEW L KOOYMAN
Credential	:	DDS
Telephone Number	:	208-899-2384

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	06/19/2018

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Directions to “IDAHO SLEEP AND WELLNESS LLC ” Practice Location

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