Provider Demographics
NPI:1407965130
Name:SLEEP CENTER OF CENTRAL ILLINOIS LLC
Entity Type:Organization
Organization Name:SLEEP CENTER OF CENTRAL ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-663-9999
Mailing Address - Street 1:2204 EASTLAND DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-662-1558
Mailing Address - Fax:309-662-1390
Practice Address - Street 1:2204 EASTLAND DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3567
Practice Address - Country:US
Practice Address - Phone:309-662-1558
Practice Address - Fax:309-662-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732085OtherBLUE CROSS BLUE SHIELD
IL5732085OtherBLUE CROSS BLUE SHIELD