Provider Demographics
NPI:1790934834
Name:SAN GABRIEL VALLEY SLEEP LAB, LLC
Entity Type:Organization
Organization Name:SAN GABRIEL VALLEY SLEEP LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOS SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-772-8282
Mailing Address - Street 1:421 S GLENDORA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3078
Mailing Address - Country:US
Mailing Address - Phone:626-919-3000
Mailing Address - Fax:
Practice Address - Street 1:421 S GLENDORA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3078
Practice Address - Country:US
Practice Address - Phone:626-919-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38413261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEX573AMedicare PIN