MEDICARE: EAST IDAHO CENTER FOR SLEEP 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

General Provider Information

NPI Number	:	1548561129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST IDAHO CENTER FOR SLEEP LLC

Provider Business Mailing Address
First Line	:	302 E HERSEY ST STE 12
Second Line	:
City	:	ASHLAND
State	:	OR
Zip	:	97520-1957
Country	:	US
Telephone Number	:	541-646-0858
Fax Number	:

Provider Business Practice Location Address
First Line	:	1341 EAST 17TH STREET
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404
Country	:	US
Telephone Number	:	208-523-7246
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DODIE R NOLES
Credential	:
Telephone Number	:	541-646-0858

Provider Enumeration Date	:	11/12/2010
Last Update Date	:	11/12/2010

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