Provider Demographics
NPI:1093965493
Name:MOTHERLODE SLEEP CENTER INC
Entity Type:Organization
Organization Name:MOTHERLODE SLEEP CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BERRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-588-8068
Mailing Address - Street 1:729 PAULINE CT
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370
Mailing Address - Country:US
Mailing Address - Phone:209-588-8068
Mailing Address - Fax:
Practice Address - Street 1:729 PAULINE CT
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370
Practice Address - Country:US
Practice Address - Phone:209-588-8068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79487207RS0012X, 261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760447031Medicare UPIN