Provider Demographics
NPI:1629137039
Name:SLEEP WELLNESS SOUTHSHORE, LLC
Entity Type:Organization
Organization Name:SLEEP WELLNESS SOUTHSHORE, LLC
Other - Org Name:THE SLEEP WELLNESS INSTITUTE, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-336-3000
Mailing Address - Street 1:2356 S 102ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2104
Mailing Address - Country:US
Mailing Address - Phone:414-336-3000
Mailing Address - Fax:414-336-1015
Practice Address - Street 1:100 15TH AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-1160
Practice Address - Country:US
Practice Address - Phone:414-336-3000
Practice Address - Fax:414-336-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1600270OtherUNITED HEALTHCARE GROUP #
WI32890000Medicaid
WI391801802029OtherANTHEM BLUE CROSS GROUP #
WI391801802002OtherTRICARE GROUP NUMBER
WI391801802029OtherCOMPCARE GROUP NUMBER
WI6758909OtherCIGNA SERVICE LINE PIN
WI1600270OtherUNITED HEALTHCARE GROUP #