Provider Demographics
NPI:1023037272
Name:SPACE COAST SLEEP DISORDERS CENTER LLC
Entity Type:Organization
Organization Name:SPACE COAST SLEEP DISORDERS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:STIGALL
Authorized Official - Suffix:
Authorized Official - Credentials:RRT, RPSGT
Authorized Official - Phone:321-255-9901
Mailing Address - Street 1:640 CLASSIC CT
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8279
Mailing Address - Country:US
Mailing Address - Phone:321-255-9901
Mailing Address - Fax:321-255-9902
Practice Address - Street 1:640 CLASSIC CT
Practice Address - Street 2:SUITE 106
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8279
Practice Address - Country:US
Practice Address - Phone:321-255-9901
Practice Address - Fax:321-255-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7135261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1065447OtherCARE PLUS
FL36521OtherWELLCARE
FL7729847OtherAETNA
FLV3120OtherBCBS
FLF301267OtherFREEDOM HEALTH
FL01092537OtherAMERI GROUP
FL7729847OtherAETNA
FL=========OtherHUMANA
FLF301267OtherFREEDOM HEALTH
FL1065447OtherCARE PLUS
FL=========OtherGREAT WEST
FLIV937AMedicare UPIN