MEDICARE: KENTUCKY SLEEP LAB 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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center

General Provider Information

NPI Number	:	1669654992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENTUCKY SLEEP LAB LLC

Provider Business Mailing Address
First Line	:	1006 NEW MOODY LN
Second Line	:	PO BOX 393
City	:	LA GRANGE
State	:	KY
Zip	:	40031-9122
Country	:	US
Telephone Number	:	502-667-0692
Fax Number	:	502-222-0390

Provider Business Practice Location Address
First Line	:	1006 NEW MOODY LN
Second Line	:	SECOND FLOOR
City	:	LA GRANGE
State	:	KY
Zip	:	40031-9122
Country	:	US
Telephone Number	:	502-667-0692
Fax Number	:	502-222-0390

Authorized Official
Title or Position	:	OWNER
Name	:	MS. NISHA DAVE
Credential	:	MBA
Telephone Number	:	502-667-0692

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	07/28/2009

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