Provider Demographics
NPI:1639284136
Name:PALMETTO SLEEP LAB LLC
Entity Type:Organization
Organization Name:PALMETTO SLEEP LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:CAPELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-444-0800
Mailing Address - Street 1:PO BOX 1226
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-1226
Mailing Address - Country:US
Mailing Address - Phone:843-444-0800
Mailing Address - Fax:843-357-1471
Practice Address - Street 1:1705 N OAK ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3580
Practice Address - Country:US
Practice Address - Phone:843-444-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPL0073Medicaid
SCPL0073Medicaid
SCQ33500Medicare UPIN