Provider Demographics
NPI:1104831809
Name:INDIANOLA SLEEP CLINIC, LLC
Entity Type:Organization
Organization Name:INDIANOLA SLEEP CLINIC, LLC
Other - Org Name:RURAL SLEEP DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HERRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-887-3700
Mailing Address - Street 1:PO BOX 1151
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-1151
Mailing Address - Country:US
Mailing Address - Phone:662-887-3700
Mailing Address - Fax:888-519-3773
Practice Address - Street 1:103 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-3500
Practice Address - Country:US
Practice Address - Phone:662-887-3700
Practice Address - Fax:888-519-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05073893Medicaid
MS20335479OtherTRICARE PROVIDER ID
MS470000068Medicare ID - Type Unspecified
MSY44459Medicare UPIN