MEDICARE: CGC 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	332B00000X	Durable Medical Equipment & Medical Supplies	200908210422	CA
2	291U00000X	Clinical Medical Laboratory	200908210422	CA

General Provider Information

NPI Number	:	1811125396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CGC SLEEP LAB LLC

Provider Business Mailing Address
First Line	:	43920 MARGARITA RD
Second Line	:	SUITE G
City	:	TEMECULA
State	:	CA
Zip	:	92592-2736
Country	:	US
Telephone Number	:	951-402-5076
Fax Number	:	951-302-4890

Provider Business Practice Location Address
First Line	:	43920 MARGARITA RD
Second Line	:	SUITE G
City	:	TEMECULA
State	:	CA
Zip	:	92592-2736
Country	:	US
Telephone Number	:	951-402-5076
Fax Number	:	951-302-4890

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LEONARD JOAQUIN SANTOS
Credential	:
Telephone Number	:	951-402-5076

Provider Enumeration Date	:	06/23/2009
Last Update Date	:	06/23/2009

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