Provider Demographics
NPI:1275759441
Name:IDAHO SLEEP SERVICES, LLC
Entity Type:Organization
Organization Name:IDAHO SLEEP SERVICES, LLC
Other - Org Name:IDAHO SLEEP HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-463-3000
Mailing Address - Street 1:PO BOX 3291
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3291
Mailing Address - Country:US
Mailing Address - Phone:208-375-8222
Mailing Address - Fax:208-375-8232
Practice Address - Street 1:210 GEORGIA AVE
Practice Address - Street 2:STE 120
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-442-8222
Practice Address - Fax:208-442-8232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9815174400000X
177F00000X, 293D00000X
ID261QS1200X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No177F00000XOther Service ProvidersLodgingGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790388Medicare PIN