Provider Demographics
NPI:1740335991
Name:IDAHO DIAGNOSTIC SLEEP LAB, INC.
Entity type:Organization
Organization Name:IDAHO DIAGNOSTIC SLEEP LAB, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-736-7646
Mailing Address - Street 1:526 SHOUP AVE W STE C
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5050
Mailing Address - Country:US
Mailing Address - Phone:208-736-7646
Mailing Address - Fax:208-736-1569
Practice Address - Street 1:2423 S GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4477
Practice Address - Country:US
Practice Address - Phone:208-736-7646
Practice Address - Fax:208-736-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149908OtherBLUE SHIELD OF IDAHO
OR232489Medicaid
ID8L378OtherBLUE CROSS OF IDAHO
OR232489Medicaid