Provider Demographics
NPI:1427100270
Name:SLEEP DISORDER CENTER OF EASTERN IDAHO, INC.
Entity type:Organization
Organization Name:SLEEP DISORDER CENTER OF EASTERN IDAHO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:POLYSOMNOGRAPHIST
Authorized Official - Phone:208-524-8044
Mailing Address - Street 1:2001 S WOODRUFF
Mailing Address - Street 2:STE 11
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-524-8044
Mailing Address - Fax:208-525-8896
Practice Address - Street 1:2001 S WOODRUFF
Practice Address - Street 2:STE 11
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-8044
Practice Address - Fax:208-525-8896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
8A646OtherBLUE CROSS
000010001762OtherBLUE SHIELD
ID805240900Medicaid
000010001762OtherBLUE SHIELD