Provider Demographics
NPI:1609964964
Name:ISLAND SLEEP LAB LLC
Entity Type:Organization
Organization Name:ISLAND SLEEP LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-842-9919
Mailing Address - Street 1:58 SHELTER COVE LANE
Mailing Address - Street 2:SUITE E1
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928
Mailing Address - Country:US
Mailing Address - Phone:843-842-9919
Mailing Address - Fax:843-842-9963
Practice Address - Street 1:58 SHELTER COVE LANE
Practice Address - Street 2:SUITE E1
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928
Practice Address - Country:US
Practice Address - Phone:843-842-9919
Practice Address - Fax:843-842-9963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPL0083Medicaid
SCQ33840001Medicare ID - Type Unspecified