Provider Demographics
NPI:1174771018
Name:SLEEP SOURCE KENTUCKY, LLC
Entity type:Organization
Organization Name:SLEEP SOURCE KENTUCKY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEXTON
Authorized Official - Suffix:
Authorized Official - Credentials:RRT, RPSGT
Authorized Official - Phone:270-575-0080
Mailing Address - Street 1:105 NOLAN AVE
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:KY
Mailing Address - Zip Code:42041-8220
Mailing Address - Country:US
Mailing Address - Phone:270-575-0080
Mailing Address - Fax:270-575-0081
Practice Address - Street 1:3125 PARISA DRIVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
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:2008-09-04
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9377901Medicare PIN