Provider Demographics
NPI:1114963048
Name:ILLINOIS SLEEP PROVIDER, INC.
Entity Type:Organization
Organization Name:ILLINOIS SLEEP PROVIDER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEJANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-442-9800
Mailing Address - Street 1:8736 W ODGEN AVE
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IL
Mailing Address - Zip Code:60534-1060
Mailing Address - Country:US
Mailing Address - Phone:708-442-9800
Mailing Address - Fax:708-442-9889
Practice Address - Street 1:8736 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1060
Practice Address - Country:US
Practice Address - Phone:708-442-9800
Practice Address - Fax:708-442-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000618332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203.000618OtherSTATE OF ILLINOIS LICENSE
IL01633937OtherBCBS PROVIDER NUMBER
IL194.003094OtherSTATE OF ILL. LICENSE
IL=========001Medicaid
IL5090930001Medicare ID - Type UnspecifiedPROVIDER NUMBER