Provider Demographics
NPI:1629032149
Name:SLEEP LABS OF THE DEEP SOUTH LLC
Entity Type:Organization
Organization Name:SLEEP LABS OF THE DEEP SOUTH LLC
Other - Org Name:DEEP SOUTH SLEEP DISORDERS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ESTELLE
Authorized Official - Last Name:GAYLORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-925-3357
Mailing Address - Street 1:382 B CARRIAGE HOUSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2299
Mailing Address - Country:US
Mailing Address - Phone:731-664-8716
Mailing Address - Fax:731-664-8932
Practice Address - Street 1:13702 COURSEY BOULEVARD
Practice Address - Street 2:BUILDING 4 SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1370
Practice Address - Country:US
Practice Address - Phone:225-925-3357
Practice Address - Fax:225-924-9863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
G6949OtherBCBS LA
LA5DA52Medicare PIN