Provider Demographics
NPI:1669654992
Name:KENTUCKY SLEEP LAB LLC
Entity Type:Organization
Organization Name:KENTUCKY SLEEP LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:502-667-0692
Mailing Address - Street 1:1006 NEW MOODY LN
Mailing Address - Street 2:PO BOX 393
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9122
Mailing Address - Country:US
Mailing Address - Phone:502-667-0692
Mailing Address - Fax:502-222-0390
Practice Address - Street 1:1006 NEW MOODY LN
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9122
Practice Address - Country:US
Practice Address - Phone:502-667-0692
Practice Address - Fax:502-222-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherEIN