Provider Demographics
NPI:1720232796
Name:SLEEP SOURCE KENTUCKY, LLC
Entity Type:Organization
Organization Name:SLEEP SOURCE KENTUCKY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-575-0080
Mailing Address - Street 1:3125 PARISA DRIVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-4584
Mailing Address - Country:US
Mailing Address - Phone:270-575-0080
Mailing Address - Fax:270-575-0081
Practice Address - Street 1:3125 PARISA DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4584
Practice Address - Country:US
Practice Address - Phone:270-575-0080
Practice Address - Fax:270-575-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730079261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9372501Medicare PIN